Early Invasive Strategy for Unstable Angina: a New Meta-Analysis of Old Clinical Trials.
Randomized controlled trials (RCTs) were conflicting to support whether unstable angina versus non-ST-elevation myocardial infarction (UA/NSTEMI) patients best undergo early invasive or a conservative revascularization strategy. RCTs with cardiac biomarkers, in MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from 1975-2013 were reviewed considering all cause mortality, recurrent non-fatal myocardial infarction (MI) and their combination. Follow-up lasted from 6-24 months and the use of routine invasive strategy up to its end was associated with a significantly lower composite of all-cause mortality and recurrent non-fatal MI (Relative Risk [RR] 0.79; 95% confidence interval [CI], 0.70-0.90) in UA/NSTEMI. In NSTEMI, by the invasive strategy, there was no benefit (RR 1.19; 95% CI, 1.03-1.38). In the shorter time period, from randomization to discharge, a routine invasive strategy was associated with significantly higher odds of the combined end-point among UA/NSTEMI (RR 1.29; 95% CI, 1.05-1.58) and NSTEMI (RR 1.82; 95% CI, 1.34-2.48) patients. Therefore, in trials recruiting a large number of UA patients, by routine invasive strategy the largest benefit was seen, whereas in NSTEMI patients death and non-fatal MI were not lowered. Routine invasive treatment in UA patients is accordingly supported by the present study.
Department of Experimental, Diagnostics and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy.
Olivia
O
Manfrini
Department of Experimental, Diagnostics and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy.
Beatrice
B
Ricci
Department of Medical and Surgical Sciences, University of Bologna, Via S. Giacomo 12, 40126 Bologna, Italy.
Ada
A
Dormi
Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
Paolo Emilio
PE
Puddu
Department of Experimental, Diagnostics and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy.
Edina
E
Cenko
Department of Experimental, Diagnostics and Specialty Medicine, University of Bologna, Via Giuseppe Massarenti 9, 40138 Bologna, Italy.
Raffaele
R
Bugiardini
D000789:Angina, Unstable / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D016019:Survival Analysis; D016896:Treatment Outcome