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Early invasive strategy fails to reduce mortality in NSTEACS
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In the overall non-ST-elevation ACS population, early invasive strategies did not significantly reduce mortality rates compared with delayed invasive strategies, according to data published in The Lancet.
“Guidelines for timing of coronary angiography in non-ST-elevation ACS (NSTEACS) are based on results of individual randomized controlled trials and several meta-analyses,” Alexander Jobs, MD, from the department of cardiology, angiology and intensive care medicine at the University Heart Center Lübeck, Medical Clinic II in Lübeck, Germany, and colleagues wrote. “However, individual trials were underpowered to detect an effect on mortality. The meta-analyses were methodologically limited by their use of published data, which precluded subgroup analyses because of inconsistent trial reporting.”
The researchers conducted a collaborative meta-analysis of published and unpublished data from trials that studied timing of coronary angiography in NSTEACS to assess the effect of timing on mortality.
Eight trials that reported all-cause mortality at least 30 days after in-hospital randomization and those in which the researchers collaborated were included in the study.
The researchers pooled HRs using random-effects models.
The trials included 5,324 patients with a median follow-up of 180 days (interquartile range, 180-360).
Among the early invasive group, there was no significant mortality reduction compared with the delayed patient set (HR = 0.81; 95% CI, 0.64-1.03).
In a prespecified analyses of high-risk patients, mortality was reduced with an early invasive strategy among patients with elevated cardiac biomarkers at baseline (HR = 0.761; 95% CI, 0.581-0.996), diabetes (HR = 0.67; 95% CI, 0.45-0.99), a Global Registry of Acute Coronary Events (GRACE) risk score more than 140 (HR = 0.7; 95% CI, 0.52-0.95) and age at least 75 years (HR = 0.65; 95% CI, 0.46-0.93). Tests for interaction, however, were inconclusive.
“Our findings, particularly concerning high-risk patients, strengthen guideline recommendations to use an early invasive approach in patients with elevated biomarkers compatible with MI or patients with GRACE risk score of more than 140 points,” the researchers wrote. “In addition, our results might indicate the need for an early invasive strategy for older patients or patients with diabetes.” – by Dave Quaile
Disclosures: The authors report no relevant financial disclosures.
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