title: Meta-Analysis of Randomized Trials of Long-Term All-Cause Mortality in Patients With Non-ST-Elevation Acute Coronary Syndrome Managed With Routine Invasive Versus Selective Invasive Strategies.
abstract: Randomized trials and meta-analyses demonstrated that a routine invasive strategy improves outcomes in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) compared to a selective invasive strategy. Benefit was driven primarily by a reduction in the risk of myocardial infarction. However, the impact of either strategy on long-term mortality is unknown. Trials that compared a routine invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and reported data on all-cause mortality ≥1 year were included. Summary odds ratios (OR) were constructed using Peto's model for all-cause mortality using the longest available follow-up data. Subgroup analysis was performed for follow-up at 1 to ≤5 years and >5 years. Eight trials with 6,657 patients were available for analysis. At a mean of 10.3 years, the risk of all-cause mortality was similar with both strategies (28.5% vs 28.5%; OR 1.00, 95% confidence interval [CI] 0.90 to 1.12, p = 0.97). This effect was similar on subgroup analysis for follow-up at 1 to ≤5 years (OR 0.89, 95% CI 0.77 to 1.04, p = 0.15) and >5 years (OR 1.02, 95% CI 0.90 to 1.14, p = 0.79). There was no difference in treatment effect across various study-level covariates such as age, gender, diabetes, and positive troponin (all P for interaction >0.05). In conclusion, in patients with NSTE-ACS, both routine invasive and selective invasive strategies have a similar risk of all-cause mortality at ∼10 years. This illustrates there are still opportunities to change the trajectory of mortality events among invasively treated patients with NSTE-ACS.
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida.
authors.forename: Islam Y
authors.initials: IY
authors.lastname: Elgendy
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida.
authors.forename: Ahmed N
authors.initials: AN
authors.lastname: Mahmoud
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida; Department of Pharmacology and Health Outcome, University of Rhode Island, Kingston, Rhode Island.
authors.forename: Xuerong
authors.initials: X
authors.lastname: Wen
authors.affiliation: Department of Medicine, University of Florida, Gainesville, Florida; North Florida/South Georgia Veterans Health System, Gainesville, Florida. Electronic address: anthony.bavry@va.gov.
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Bavry
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D000789:Angina, Unstable / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000628:therapy*; D002423:Cause of Death; D000072700:Conservative Treatment; D017023:Coronary Angiography; D019468:Disease Management; D004562:Electrocardiography; D006801:Humans; D009026:Mortality; D062645:Percutaneous Coronary Intervention; D016032:Randomized Controlled Trials as Topic