Early invasive versus conservative strategies for unstable angina & non-ST-elevation myocardial infarction in the stent era.
BACKGROUND
In patients with unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) two strategies are possible: a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia.


OBJECTIVE
To determine the benefits of an invasive compared to a conservative strategy for treating UA/NSTEMI in the stent era.


METHODS
The Cochrane Central Register of Controlled Trials (Issue 3 2005), MEDLINE and EMBASE were searched from 1996 to September 2005 with no language restrictions.


METHODS
Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI.


METHODS
We identified 5 studies (7818 participants). Using intention-to-treat analysis with random effects models, summary estimates of relative risk (95% confidence interval [CI]) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction; all-cause death or non-fatal myocardial infarction; and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using chi-square and variance (I(2)) methods.


RESULTS
In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy; relative risk 1.59 (95% CI 0.96 to 2.64). Mortality and myocardial infarction assessed at 2-5 years in two trials were significantly decreased by an invasive strategy with relative risk of 0.75 (95% CI 0.62 to 0.92) and 0.75 (95% CI 0.61 to 0.91) respectively. The composite end-point of death or non-fatal myocardial infarction was significantly decreased by an invasive strategy at several time points after initial hospitalization. The incidence of early (<4 months) and intermediate (6-12 months) refractory angina were both significantly decreased by an invasive strategy; relative risk 0.47 (95% CI 0.32 to 0.68) and 0.67 (95% CI 0.55 to 0.83) respectively, as were early and intermediate rehospitalization rates with relative risk 0.60 (95% CI 0.41 to 0.88) and 0.67 (95% CI 0.61 to 0.74) respectively. The invasive strategy was associated with a two-fold increase in the relative risk of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the relative risk of bleeding.


CONCLUSIONS
An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI.
Hoenig
M R
MR
Centre for Research in Vascular Biology, Australian Institute for Bioengineering and Nanotechnology, University of Queensland, Brisbane, QLD, Australia 4072. drmhoenig@yahoo.com.au
Doust
J A
JA
Aroney
C N
CN
Scott
I A
IA
D000789:Angina, Unstable / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000401:mortality / Q000601:surgery / Q000628:therapy*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D016032:Randomized Controlled Trials as Topic; D012737:Sex Factors; D015607:Stents
D019039:Platelet Glycoprotein GPIIb-IIIa Complex