RSS Feeds
Possible Benefit to Survival from Early Invasive Strategies in Patients with Acute Coronary Syndromes
- Rehan Qayyum, MD;
- Jurga Adomaityte, MD; and
- M. Rizwan Khalid, MD
- From Johns Hopkins School of Medicine, Baltimore, MD 21287, and New York Hospital Queens, Flushing, NY 11355.
IN RESPONSE:
We appreciate Drs. Kumbhani and Bavry's interest in our systematic review. They suggest that excluding 3 trials (TIMI IIIB, VANQWISH, and MATE) that were performed before the current era of glycoprotein IIb/IIIa and coronary stenting would yield different results. When we excluded these 3 trials from meta-analyses, our results did not change (relative risk for death, 0.88 [95% CI, 0.72 to 1.07]; for nonfatal myocardial infarction, 0.82 [CI, 0.57 to 1.17]; and for combined death and nonfatal myocardial infarction, 0.84 [CI, 0.63 to 1.10]).
The discrepancy between our results and the 2 meta-analyses (1, 2) by Bavry and colleagues is due not to inclusion of older trials but to differences in study inclusion criteria. The 2 meta-analyses by Bavry and colleagues included the ISAR-COOL (Intracoronary Stenting with Antithrombotic Regimen Cooling Off) trial (3). We excluded that trial because it did not compare routine invasive with selective invasive strategy. Instead, it compared 3 to 5 days of antithrombotic treatment with less than 6 hours of treatment before coronary intervention. Because almost all patients in this trial underwent angiography within 5 days of randomization, it does not have a selective invasive strategy group and, in our view, should not be included in a comparative systematic review of the 2 strategies.
Drs. Kumbhani and Bavry contend that we should have included only trials that performed coronary intervention according to current standards of care. One can extend this and argue that only trials that meet current standards of care for both coronary intervention and pharmacologic therapy should be included in a systematic review. This would leave only 1 trial, ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) (4), which used both glycoprotein IIb/IIIa and coronary stents and had more than 90% of patients receiving statins. This trial, which provided the currently accepted standard of care to enrolled patients, found a statistically significant benefit for the selective invasive strategy over routine invasive strategy.
Rehan Qayyum, MD
Jurga Adomaityte, MD
Johns Hopkins School of Medicine
Baltimore, MD 21287
Article and Author Information
-
Potential Financial Conflicts of Interest: None disclosed.
