Meta-analysis of Randomized Trials of Long-term All-cause Mortality in Patients with Non-ST-elevation Acute Coronary Syndrome Managed with a Routine Invasive versus Selective Invasive Strategies

• Published in: The American journal of cardiology Vol. 119; no. 4; pp. 560 - 564
• Main Authors: Elgendy, Islam Y., MD, Mahmoud, Ahmed N., MD, Wen, Xuerong, PhD, Bavry, Anthony A., MD, MPH
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 15-02-2017; Elsevier Limited
• Subjects: Acute Coronary Syndrome - diagnostic imaging; Acute Coronary Syndrome - physiopathology; Acute Coronary Syndrome - therapy; Acute coronary syndromes; Age; Angina pectoris; Angina, Unstable - diagnostic imaging; Angina, Unstable - physiopathology; Angina, Unstable - therapy; Bias; Cardiology; Cardiovascular; Cardiovascular disease; Cause of Death; Conservative Treatment; Coronary Angiography; Diabetes; Disease Management; Electrocardiography; Health risk assessment; Heart attacks; Humans; Ischemia; Medical imaging; Medical prognosis; Meta-analysis; Mortality; Patients; Percutaneous Coronary Intervention; Randomized Controlled Trials as Topic; Studies; meta-analysis; mortality; acute coronary syndrome
• ISSN: 0002-9149; 1879-1913
• DOI: 10.1016/j.amjcard.2016.11.005

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 with 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] 0.90-1.12, P=0.97). This effect was similar on subgroup analysis for follow up at 1 to ≤ 5 years (OR 0.89, 95% CI 0.77-1.04, P=0.15), and > 5 years (OR 1.02, 95% CI 0.90-1.14, 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 NSTE-ACS patients.