Do patients with non-ST-elevation acute coronary syndromes fare better if they have early angiography or delayed angiography?

In general, the timing of angiography in patients with non-ST-elevation acute coronary syndromes has no effect on mortality or nonfatal myocardial infarction. Whether there are subgroups of patients that might benefit warrants further study. (LOE = 1a)

Jobs A, Mehta SR, Montalescot G, et al. Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet. 2017;390(10096):737-746.  [PMID:28778541]

Meta-analysis (randomized controlled trials)

Self-funded or unfunded

Emergency department

These authors searched 2 databases and the Cochrane clinical trials register to identify randomized trials that compared early versus delayed coronary angiography in patients with non-ST-elevation acute coronary syndromes. Two authors independently assessed the methodologic quality of the included studies and resolved discrepancies through consensus. They evaluated the primary outcome, all-cause mortality, by intention to treat. Ultimately they included 8 trials with 5324 patients. All the included trials were of low risk of bias. The median follow-up ranged from 30 days to 732 days. During the follow-up period, 277 (5%) of the patients died (nearly half occurred during the index hospitalization). There was no significant difference in the mortality rate if the patients underwent early or delayed angiography. Additionally, there was no difference in the rate of nonfatal myocardial infarction. Although some subgroups had a slightly lower death rate with early intervention (patients with diabetes, elevated cardiac biomarkers, or older than 75 years), the numbers are small and not very robust.