Systematic Review: Comparing Routine and Selective Invasive Strategies for the Acute Coronary Syndrome

5 February 2008 | Volume 148 Issue 3 | Pages 186-196

Background: Patients with non–ST-segment elevation acute coronary syndrome (ACS) are managed with either a routine invasive strategy, in which all patients receive coronary angiography, or a selective invasive strategy, in which only patients with refractory or inducible ischemia receive coronary angiography.

Purpose: To evaluate whether a routine invasive strategy improves cardiovascular outcomes more than a selective invasive strategy in patients with non–ST-segment elevation ACS.

Data Sources: English-language publications in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from 1966 to 18 September 2007.

Study Selection: Two investigators independently reviewed searches and selected trials that compared death or myocardial infarction outcomes among adults with non–ST-segment elevation ACS by randomly assigning patients to either a routine invasive strategy or a selective invasive strategy.

Data Extraction: Three investigators independently abstracted data from trial reports by using standardized forms.

Data Synthesis: 10 trials with a total of 10 648 patients (mean age, 62 years; 71% male; median follow-up, 16.5 months) were found. Trial participants had typical symptoms of unstable angina and frequently had a positive electrocardiogram or marker evidence of myocardial ischemia. Of the 5330 participants assigned to the routine invasive strategy group, 847 had the composite outcome of death or nonfatal myocardial infarction, compared with 928 of 5318 participants assigned to the selective invasive strategy group (relative risk, 0.90 [95% CI, 0.74 to 1.08]). Four hundred thirty-eight patients in the routine invasive strategy group and 463 in the selective invasive strategy group died (relative risk, 0.95 [CI, 0.80 to 1.14]). Four hundred ninety and 569 nonfatal myocardial infarctions, respectively, occurred in the 2 groups (relative risk, 0.86 [CI, 0.68 to 1.08]).

Limitations: Methodology, protocols, and outcome definitions differed substantially among the trials. The lower bound of the CI for the pooled results did not rule out the superiority of the routine invasive strategy.

Conclusion: Available trial evidence is heterogeneous and insufficient for comparing routine and selective invasive strategies. Therefore, in patients with non–ST-segment elevation ACS a routine invasive strategy cannot be proven to reduce deaths or nonfatal myocardial infarction.

Editors' Notes Context Patients with non–ST-segment elevation acute coronary syndrome (ACS) may have coronary angiography routinely or selectively (that is, only if they have refractory or inducible ischemia). Contribution This systematic review of 10 randomized trials involving 10 648 patients with non–ST-segment elevation ACS found that 15.9% of participants assigned to a routine invasive strategy died or had nonfatal myocardial infarction, compared with 17.5% of those assigned to a selective invasive strategy (relative risk, 0.90 [95% CI, 0.74 to 1.08]). Caution Intervention protocols of trials differed substantially. Implication Trial evidence does not clearly establish the superiority of a routine over a selective invasive strategy for patients with non–ST-segment elevation ACS. —The Editors

 

Author and Article Information

From John Hopkins Hospital, Baltimore, Maryland, and New York Hospital Queens, Flushing, New York.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Rehan Qayyum, MD, Johns Hopkins Hospital, Hospitalist Program, 600 North Wolfe Street, Park 307-A, Baltimore, MD 21287; e-mail, rqayyum{at}jhmi.edu.

Current Author Addresses: Drs. Qayyum and Adomaityte: Johns Hopkins Hospital, Hospitalist Program, 600 North Wolfe Street, Park 307-A, Baltimore, MD 21287.

Drs. Khalid, Papadakos, and Messineo: Kyrenia Heart Center, New York Hospital Queens, 5645 Main Street, Flushing, New York 11355.

Author Contributions: Conception and design: R. Qayyum, M.R. Khalid, J. Adomaityte.

Analysis and interpretation of the data: R. Qayyum, M.R. Khalid, J. Adomaityte, S.P. Papadakos, F.C. Messineo.

Drafting of the article: R. Qayyum, M.R. Khalid, J. Adomaityte, S.P. Papadakos, F.C. Messineo.

Critical revision of the article for important intellectual content: R. Qayyum, M.R. Khalid, S.P. Papadakos, FC. Messineo.

Final approval of the article: R. Qayyum, M.R. Khalid, J. Adomaityte, S.P. Papadakos, F.C. Messineo.

Statistical expertise: R. Qayyum, M.R. Khalid.

Administrative, technical or logistic support: M.R. Khalid.

Collection and assembly of data: R. Qayyum, M.R. Khalid, J. Adomaityte.

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