title: Optimal timing of coronary invasive strategy in non-ST-segment elevation acute coronary syndromes: a systematic review and meta-analysis.
abstract: The optimal timing of coronary intervention in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACSs) is a matter of debate. Conflicting results among published studies partly relate to different risk profiles of the studied populations.
  
  
  
  To do the most comprehensive meta-analysis of current evidence on early versus delayed invasive treatment in NSTE-ACS.
  
  
  
  MEDLINE, PubMed Central, and Google Scholar databases; conference proceedings; ClinicalTrials.gov registry; and Current Controlled Trials registry through May 2012.
  
  
  
  Available randomized, controlled trials (RCTs) and observational studies comparing early versus delayed intervention in the NSTE-ACS population.
  
  
  
  Data were extracted for populations, interventions, outcomes, and risk of bias. All-cause mortality was the prespecified primary end point. The longest follow-up available in each study was chosen. The odds ratio with 95% CI was the effect measure.
  
  
  
  Seven RCTs (5370 patients) and 4 observational studies (77 499 patients) were included. Early intervention was less than 20 hours after hospitalization or randomization for RCTs and 24 hours or less for observational studies. Meta-analysis of the RCTs was inconclusive for a survival benefit associated with the early invasive strategy (odds ratio, 0.83 [95% CI, 0.64 to 1.09]; P = 0.180); a similar result emerged from the observational studies. With early versus late intervention, the odds ratios in the RCTs were 1.15 (CI, 0.65 to 2.01; P = 0.63) and 0.76 (CI, 0.56 to 1.04; P = 0.090) for myocardial infarction and major bleeding during follow-up, respectively.
  
  
  
  Current evidence from RCTs is limited by the small overall sample size, low numbers of events in some trials, and heterogeneity in the timing of intervention and in patient risk profiles.
  
  
  
  At present, there is insufficient evidence either in favor of or against an early invasive approach in the NSTE-ACS population. A more definitive RCT is warranted to guide clinical practice.
authors: Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
authors: Eliano P
authors: EP
authors: Navarese
authors: Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
authors: Paul A
authors: PA
authors: Gurbel
authors: Catholic University of the Sacred Heart, Rome, Italy
authors: Felicita
authors: F
authors: Andreotti
authors: Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
authors: Udaya
authors: U
authors: Tantry
authors: Sinai Center for Thrombosis Research, Sinai Hospital of Baltimore, Baltimore, Maryland
authors: Young-Hoon
authors: YH
authors: Jeong
authors: Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
authors: Marek
authors: M
authors: Kozinski
authors: Rigshospitalet, Copenhagen, Denmark
authors: Thomas
authors: T
authors: Engstrøm
authors: Unità Ospedaliera di Cardiologia, Ospedale Maggiore, Bologna, Italy
authors: Giuseppe
authors: G
authors: Di Pasquale
authors: Medical University of Gdansk, Swissmed Hospital, Gdansk, Poland
authors: Waclaw
authors: W
authors: Kochman
authors: Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
authors: Diego
authors: D
authors: Ardissino
authors: Maasstad Ziekenhuis, Rotterdam, the Netherlands
authors: Elvin
authors: E
authors: Kedhi
authors: Columbia University Medical Center/New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York
authors: Gregg W
authors: GW
authors: Stone
authors: Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Bydgoszcz, Poland
authors: Jacek
authors: J
authors: Kubica
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000401:mortality / Q000601:surgery*; D001026:Coronary Artery Bypass; D006470:Hemorrhage / Q000453:epidemiology; D006801:Humans; D009203:Myocardial Infarction / Q000453:epidemiology; D009204:Myocardial Revascularization; D062645:Percutaneous Coronary Intervention; D011183:Postoperative Complications / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D015983:Selection Bias; D013997:Time Factors; D016896:Treatment Outcome