title: Timing of Coronary Invasive Strategy in Non-ST-Segment Elevation Acute Coronary Syndromes and Clinical Outcomes: An Updated Meta-Analysis.
abstract: The aim of this study was to compare an early versus a delayed invasive strategy in non-ST-segment elevation acute coronary syndromes by performing a meta-analysis of all available randomized controlled clinical trials.
  
  
  
  An invasive approach is recommended to prevent death and myocardial infarction in non-ST-segment elevation acute coronary syndromes. However, the timing of angiography and the subsequent intervention, when required, remains controversial.
  
  
  
  A previous meta-analysis of 7 randomized clinical trials comparing early and delayed invasive strategies in non-ST-segment elevation acute coronary syndromes with 3 new randomized clinical trials identified in a search of the published research (n = 10 trials, n = 6,397 patients) was updated.
  
  
  
  The median time between randomization and angiography ranged from 0.5 to 14.0 h in the early group and from 18.3 to 86.0 h in the delayed group. There was no difference in the primary endpoint of mortality (4% vs. 4.7%; random-effects odds ratio [OR]: 0.85; 95% confidence interval [CI]: 0.67 to 1.09; p = 0.20; I2= 0%). The rate of myocardial infarction was also similar (6.7% vs. 7.7%; random-effects OR: 0.88; 95% CI: 0.53 to 1.45; p = 0.62; I2= 77.5%). An early strategy was associated with a reduction in recurrent ischemia or refractory angina (3.8% vs. 5.8%; random-effects OR: 0.54; 95% CI: 0.40 to 0.74; p < 0.01; I2= 28%) and a shorter in-hospital stay (median 112 h [interquartile range: 61 to 158 h] vs. 168 h [interquartile range: 90.3 to 192 h]; random-effects standardized mean difference -0.40; 95% CI: -0.59 to -0.21; p < 0.01; I2= 79%). Major bleeding was similar in the 2 groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p = 0.64; I2= 0%).
  
  
  
  An early invasive strategy does not reduce the risk for death or myocardial infarction compared with a delayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.
authors.affiliation: Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; Aix-Marseille Université, INSERM UMR-S 1076, Vascular Research Center of Marseille, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France. Electronic address: laurentbonello@yahoo.fr.
authors.forename: Laurent
authors.initials: L
authors.lastname: Bonello
authors.affiliation: Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Laine
authors.affiliation: Département de Cardiologie, Hôpital Européen Georges Pompidou, Assistance Publique des Hôpitaux de Paris, Paris, France; Université Paris Descartes, INSERM U-970, Paris, France.
authors.forename: Etienne
authors.initials: E
authors.lastname: Puymirat
authors.affiliation: Service d'Accueil des Urgences, Hôpital Timone, Marseille, France.
authors.forename: Gilles
authors.initials: G
authors.lastname: Lemesle
authors.affiliation: Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France.
authors.forename: Franck
authors.initials: F
authors.lastname: Thuny
authors.affiliation: Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France.
authors.forename: Franck
authors.initials: F
authors.lastname: Paganelli
authors.affiliation: MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Département de Cardiologie, CHU de Lille, Lille, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Michelet
authors.affiliation: MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Service d'Accueil des Urgence, Hôpital Nord, Marseille, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Roch
authors.affiliation: MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France; Pole RUSH, Assistance-Publique Hôpitaux de Marseille, Marseille, France.
authors.forename: François
authors.initials: F
authors.lastname: Kerbaul
authors.affiliation: EA 3279-Public Health, Chronic Diseases and Quality of Life-Research Unit, Aix-Marseille University, Marseille, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Boyer
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D000072658:Non-ST Elevated Myocardial Infarction / Q000000981:diagnostic imaging / Q000401:mortality / Q000628:therapy*; D016017:Odds Ratio; D062645:Percutaneous Coronary Intervention / Q000009:adverse effects / Q000401:mortality; D016032:Randomized Controlled Trials as Topic; D012008:Recurrence; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
keywords: NSTE-ACS; angiography; invasive; mortality; percutaneous coronary intervention; timing