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Review
. 2017 Nov 27:8:952.
doi: 10.3389/fphys.2017.00952. eCollection 2017.

Immediate/Early vs. Delayed Invasive Strategy for Patients with Non-ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-Analysis

Yanda Li  1 , Zhenpeng Zhang  1 , Xingjiang Xiong  1 , William C Cho  2 , Dan Hu  3 , Yonghong Gao  4 , Hongcai Shang  4 , Yanwei Xing  1
Affiliations
Review

Immediate/Early vs. Delayed Invasive Strategy for Patients with Non-ST-Segment Elevation Acute Coronary Syndromes: A Systematic Review and Meta-Analysis

Yanda Li et al. Front Physiol. .

Abstract

Invasive coronary revascularization has been shown to improve prognoses in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS), but the optimal timing of intervention remains unclear. This meta-analysis is to evaluate the outcomes in immediate (<2 h), early (<24 h), and delayed invasive group and find out which is the optimal timing of intervention in NSTE-ACS patients. Studies were identified through electronic literature search of Medline, PubMed Central, Embase, the Cochrane Library, and CNKI. Data were extracted for populations, interventions, outcomes, and risk of bias. All-cause mortality was the pre-specified primary end point. The longest follow-up available in each study was chosen. The odds ratio (OR) with 95% CI was the effect measure. The fixed or random effect pooled measure was selected based on the heterogeneity test among studies. In the comparison between early and delayed intervention, we found that early intervention led to a statistical significant decrease in mortality rate (n = 6,624; OR 0.78, 95% CI: 0.61-0.99) and refractory ischemia (n = 6,127; OR 0.50, 95% CI: 0.40-0.62) and a non-significant decrease in myocardial infarction (MI), major bleeding and revascularization. In the analysis comparing immediate and delayed invasive approach, we found that immediate intervention significantly reduced major bleeding (n = 1,217; OR 0.46, 95% CI: 0.23-0.93) but led to a non-significant decrease in mortality rate, refractory ischemia and revascularization and a non-significant increase in MI. In conclusion, early invasive strategy may lead to a lower mortality rate and reduce the risk of refractory ischemia, while immediate invasive therapy shows a benefit in reducing the risk of major bleeding.

Keywords: intervention; invasive strategy; major bleeding; meta-analysis; mortality rate; non-ST-segment elevation acute coronary syndrome (NSTE-ACS).

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Figures

Figure 1
Figure 1
Flow chart of the study selection process.
Figure 2
Figure 2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
Figure 3
Figure 3
Risk of bias summary: review authors judgements about each risk of bias item for each included study.
Figure 4
Figure 4
Funnel plot for publication bias. (A) Mortality, (B) myocardial infarction, and (C) major bleeding.
Figure 5
Figure 5
Forest plots comparing outcomes between early (<24 h) invasive group and delayed invasive group. (A) Mortality, (B) myocardial infarction, (C) refractory Ischemia, (D) major bleeding, and (E) repeated revascularization.
Figure 6
Figure 6
Forest plots comparing outcomes between immediate (<2) invasive group and delayed invasive group. (A) Mortality, (B) myocardial infarction, (C) refractory ischemia, (D) major bleeding, and (E) repeated revascularization.
Figure 7
Figure 7
Forest plot comparing major bleeding between immediate (<6 h) invasive group and delayed invasive group.
Figure 8
Figure 8
TSA plot for the comparison assessing mortality rate between early (<24 h) and delayed invasive therapy.
See this image and copyright information in PMC

References

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