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Meta-Analysis
. 2022 Sep 1;43(33):3148-3161.
doi: 10.1093/eurheartj/ehac213.

Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials

Thomas A Kite  1 , Sameer A Kurmani  1 , Vasiliki Bountziouka  1 , Nicola J Cooper  1 , Selina T Lock  1 , Chris P Gale  2   3   4 , Marcus Flather  5 , Nick Curzen  6 , Adrian P Banning  7 , Gerry P McCann  1 , Andrew Ladwiniec  1
Affiliations
Meta-Analysis

Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials

Thomas A Kite et al. Eur Heart J. .

Abstract

Aims: The optimal timing of an invasive strategy (IS) in non-ST-elevation acute coronary syndrome (NSTE-ACS) is controversial. Recent randomized controlled trials (RCTs) and long-term follow-up data have yet to be included in a contemporary meta-analysis.

Methods and results: A systematic review of RCTs that compared an early IS vs. delayed IS for NSTE-ACS was conducted by searching MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. A meta-analysis was performed by pooling relative risks (RRs) using a random-effects model. The primary outcome was all-cause mortality. Secondary outcomes included myocardial infarction (MI), recurrent ischaemia, admission for heart failure (HF), repeat re-vascularization, major bleeding, stroke, and length of hospital stay. This study was registered with PROSPERO (CRD42021246131). Seventeen RCTs with outcome data from 10 209 patients were included. No significant differences in risk for all-cause mortality [RR: 0.90, 95% confidence interval (CI): 0.78-1.04], MI (RR: 0.86, 95% CI: 0.63-1.16), admission for HF (RR: 0.66, 95% CI: 0.43-1.03), repeat re-vascularization (RR: 1.04, 95% CI: 0.88-1.23), major bleeding (RR: 0.86, 95% CI: 0.68-1.09), or stroke (RR: 0.95, 95% CI: 0.59-1.54) were observed. Recurrent ischaemia (RR: 0.57, 95% CI: 0.40-0.81) and length of stay (median difference: -22 h, 95% CI: -36.7 to -7.5 h) were reduced with an early IS.

Conclusion: In all-comers with NSTE-ACS, an early IS does not reduce all-cause mortality, MI, admission for HF, repeat re-vascularization, or increase major bleeding or stroke when compared with a delayed IS. Risk of recurrent ischaemia and length of stay are significantly reduced with an early IS.

Keywords: Invasive; Mortality; Non-ST-elevation acute coronary syndrome; Percutaneous coronary intervention; Timing.

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Conflict of interest statement

Conflict of interest: S.A.K. reports personal fees from Bayer. C.P.G. reports personal fees from AstraZeneca, personal fees from Amgen, personal fees from Bayer, grants from BMS, personal fees from Boehrinher-Ingelheim, personal fees from Chiesi, personal fees from Daiichi Sankyo, personal fees from Vifor Pharma, grants from Abbott, personal fees from Menarini, personal fees from Wondr Medical, personal fees from Raisio Group, personal fees from Zydus, personal fees from Oxford University Press, grants from Abbott Diabetes, grants from BMS grants from British Heart Foundation, grants from NIHR, grant from Horizon 2020, grants from ESC, outside the submitted work. N.C. reports unrestricted research grants from Boston Scientific, HeartFlow, Beckman Coulter, and speaker/consultancy fees from Boston, Abbott, HeartFlow outside the submitted work. A.P.B. reports speaker fees from Boston Scientific, Medtronic, Abbott, and Miracor. G.P.M. reports research grants from NIHR, BHF, MRC, and AstraZeneca outside the submitted the work. The remaining authors have no conflicts of interest to declare.

Figures

Structured Graphical Abstract
Structured Graphical Abstract
Left: Time to invasive coronary angiography in the included randomized controlled trials. The bars represent median time and interquartile ranges in the early invasive strategy group (red) and the delayed invasive strategy group (blue). The Tekin et al. and Liu et al. studies are not displayed as medians were not reported. Interquartile ranges were not reported in the OPTIMA and Zhang et al. trials. Right: Summary relative risks for all-cause mortality, myocardial infarction, recurrent ischaemia, admission for heart failure, repeat revascularization, major bleeding, and stroke.
Figure 1
Figure 1
Flow diagram outlining the process of article screening and trial inclusion for the present meta-analysis.
Figure 2
Figure 2
Time to invasive coronary angiography in the included randomized controlled trials. The bars represent median time and interquartile ranges in the early invasive strategy group (left) and the delayed invasive strategy group (right). The Tekin et al. and Liu et al. studies are not displayed as medians were not reported. Interquartile ranges were not reported in the OPTIMA and Zhang et al. trials.
Figure 3
Figure 3
Individual and summary relative risks for all-cause mortality in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 4
Figure 4
Individual and summary relative risks for myocardial infarction in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 5
Figure 5
Individual and summary relative risks for recurrent ischaemia in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 6
Figure 6
Individual and summary relative risks for admission for heart failure in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 7
Figure 7
Individual and summary relative risks for repeat re-vascularization in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 8
Figure 8
Individual and summary relative risks for major bleeding in randomized controlled trials that compared early vs. delayed invasive strategies.
Figure 9
Figure 9
Individual and summary relative risks for stroke in randomized controlled trials that compared early vs. delayed invasive strategies.
See this image and copyright information in PMC

Comment in

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