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Meta-Analysis
. 2016 May 26;2016(5):CD004815.
doi: 10.1002/14651858.CD004815.pub4.

Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era

Jonathon P Fanning  1 , Jonathan Nyong, Ian A Scott, Constantine N Aroney, Darren L Walters
Affiliations
Meta-Analysis

Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era

Jonathon P Fanning et al. Cochrane Database Syst Rev. .

Abstract

Background: People with unstable angina and non-ST elevation myocardial infarction (UA/NSTEMI) are managed with a combination of medical therapy, invasive angiography and revascularisation. Specifically, two approaches have evolved: either a 'routine invasive' strategy whereby all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularisation; or a 'selective invasive' (also referred to as 'conservative') strategy in which medical therapy alone is used initially, with a selection of patients for angiography based upon evidence of persistent myocardial ischaemia. Uncertainty exists as to which strategy provides the best outcomes for these patients. This Cochrane review is an update of a Cochrane review originally published in 2006, to provide a robust comparison of these two strategies in the early management of patients with UA/NSTEMI.

Objectives: To determine the benefits and harms associated with the following.1. A routine invasive versus a conservative or 'selective invasive' strategy for the management of UA/NSTEMI in the stent era.2. A routine invasive strategy with and without glycoprotein IIb/IIIa receptor antagonists versus a conservative strategy for the management of UA/NSTEMI in the stent era.

Search methods: We searched the following databases and additional resources up to 25 August 2015: the Cochrane Central Register of Controlled Trials (CENTRAL) on the Cochrane Library, MEDLINE and EMBASE, with no language restrictions.

Selection criteria: We included prospective randomised controlled trials (RCTs) that compared invasive with conservative or 'selective invasive' strategies in participants with acute UA/NSTEMI.

Data collection and analysis: Two review authors screened the records and extracted data in duplicate. Using intention-to-treat analysis with random-effects models, we calculated summary estimates of the risk ratio (RR) with 95% confidence intervals (CIs) for the primary endpoints of all-cause death, fatal and non-fatal myocardial infarction (MI), combined all-cause death or non-fatal MI, refractory angina and re-hospitalisation. We performed further analysis of included studies based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. We assessed the heterogeneity of included trials using Pearson χ² (Chi² test) and variance (I² statistic) analysis. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, we assessed the quality of the evidence and the GRADE profiler (GRADEPRO) was used to import data from Review Manager 5.3 (Review Manager) to create Summary of findings (SoF) tables.

Main results: Eight RCTs with a total of 8915 participants (4545 invasive strategies, 4370 conservative strategies) were eligible for inclusion. We included three new studies and 1099 additional participants in this review update. In the all-study analysis, evidence did not show appreciable risk reductions in all-cause mortality (RR 0.87, 95% CI 0.64 to 1.18; eight studies, 8915 participants; low quality evidence) and death or non-fatal MI (RR 0.93, 95% CI 0.71 to 1.2; seven studies, 7715 participants; low quality evidence) with invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. There was appreciable risk reduction in MI (RR 0.79, 95% CI 0.63 to 1.00; eight studies, 8915 participants; moderate quality evidence), refractory angina (RR 0.64, 95% CI 0.52 to 0.79; five studies, 8287 participants; moderate quality evidence) and re-hospitalisation (RR 0.77, 95% CI 0.63 to 0.94; six studies, 6921 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies also at six to 12 months follow-up.Evidence also showed increased risks in bleeding (RR 1.73, 95% CI 1.30 to 2.31; six studies, 7584 participants; moderate quality evidence) and procedure-related MI (RR 1.87, 95% CI 1.47 to 2.37; five studies, 6380 participants; moderate quality evidence) with routine invasive strategies compared to conservative (selective invasive) strategies.The low quality evidence were as a result of serious risk of bias and imprecision in the estimate of effect while moderate quality evidence was only due to serious risk of bias.

Authors' conclusions: In the all-study analysis, the evidence failed to show appreciable benefit with routine invasive strategies for unstable angina and non-ST elevation MI compared to conservative strategies in all-cause mortality and death or non-fatal MI at six to 12 months. There was evidence of risk reduction in MI, refractory angina and re-hospitalisation with routine invasive strategies compared to conservative (selective invasive) strategies at six to 12 months follow-up. However, routine invasive strategies were associated with a relatively high risk (almost double the risk) of procedure-related MI, and increased risk of bleeding complications. This systematic analysis of published RCTs supports the conclusion that, in patients with UA/NSTEMI, a selectively invasive (conservative) strategy based on clinical risk for recurrent events is the preferred management strategy.

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Conflict of interest statement

JPF has no known conflicts of interest. JN has no known conflicts of interest. IAS has no known conflicts of interest. CNA received travel grants from Boston Scientific, J&J, Medtronic, MSD and Eli Lilly. DLW has been an investigator on a number of clinical research trials in the area of ACS and PCI. All funds in this regard have been paid to the institution to cover research costs. He did some paid proctoring work in the field of TAVI, which might not be directly relevant to this work.

Figures

1
1
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 1 Index death.
1.2
1.2. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 2 Early death.
1.3
1.3. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 3 Intermediate death.
1.4
1.4. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 4 Late death.
1.5
1.5. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 5 Index myocardial infarction.
1.6
1.6. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 6 Early myocardial infarction.
1.7
1.7. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 7 Intermediate myocardial infarction.
1.8
1.8. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 8 Late myocardial infarction.
1.9
1.9. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 9 Index death or non‐fatal myocardial infarction.
1.10
1.10. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 10 Early death or non‐fatal myocardial infarction.
1.11
1.11. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 11 Intermediate death or non‐fatal myocardial infarction.
1.12
1.12. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 12 Intermediate death or non‐fatal myocardial infarction; gender subanalysis.
1.13
1.13. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 13 Late death or non‐fatal myocardial infarction.
1.14
1.14. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 14 Intermediate refractory angina.
1.15
1.15. Analysis
Comparison 1 All studies undertaken in the stent era regardless of glycoprotein IIb/IIIa receptor use, Outcome 15 Intermediate rehospitalisation.
2.1
2.1. Analysis
Comparison 2 Safety endpoints, Outcome 1 Procedure‐related myocardial infarction.
2.2
2.2. Analysis
Comparison 2 Safety endpoints, Outcome 2 Bleeding.
See this image and copyright information in PMC

Update of

Comment in

References

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