Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction: a meta-analysis.
BACKGROUND
Although an invasive strategy is frequently used in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.


OBJECTIVE
To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS.


METHODS
Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.


METHODS
Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.


METHODS
The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.


RESULTS
Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).


CONCLUSIONS
In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.
O'Donoghue
Michelle
M
TIMI Study Group, Brigham and Women's Hospital, 350 Longwood Ave, First Floor, Boston, MA 02115, USA. modonoghue@partners.org
Boden
William E
WE
Braunwald
Eugene
E
Cannon
Christopher P
CP
Clayton
Tim C
TC
de Winter
Robbert J
RJ
Fox
Keith A A
KA
Lagerqvist
Bo
B
McCullough
Peter A
PA
Murphy
Sabina A
SA
Spacek
Rudolf
R
Swahn
Eva
E
Wallentin
Lars
L
Windhausen
Fons
F
Sabatine
Marc S
MS
D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality / Q000628:therapy; D000789:Angina, Unstable / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D015415:Biomarkers / Q000378:metabolism; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006760:Hospitalization; D006801:Humans; D008297:Male; D009203:Myocardial Infarction / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization; D016032:Randomized Controlled Trials as Topic; D012306:Risk; D015912:Thrombolytic Therapy; D016896:Treatment Outcome
D015415:Biomarkers; D005343:Fibrinolytic Agents