Early invasive therapy better for non-ST ACS
Clinical QuestionDoes early invasive therapy reduce mortality more than conservative treatment in patients with non-ST segment elevation acute coronary syndromes?
Bottom LineEarly invasive therapy decreases long-term mortality rates and short-term rehospitalization rates in patients with non-ST segment elevation acute coronary syndrome (ACS) without increasing acute myocardial infarction (MI) likelihood. If a hospital with a catheterization laboratory is available, send patients to that hospital. (LOE = 1a)
ReferenceBavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes. J Am Coll Cardiol 2006;48:1319-1325. [PMID:17010789]
Study DesignMeta-analysis (randomized controlled trials)
SettingInpatient (any location)
SynopsisResearch is consistent that early invasive therapy, such as bypass grafting or percutaneous intervention, for non-ST-segment elevation ACS improves overall cardiac outcomes. However, MI may be more common immediately following these procedures, and this meta-analysis combined recent trials to determine the benefit of early invasive therapy on mortality rates, MI, and recurrent unstable angina. Since studies of early invasive therapy are large and well-known, the authors used a relatively weak method of searching for relevant research. They limited the studies in their analysis to interventions that included common adjunctive treatment, including the use of glycoprotein IIb/IIIa inhibitors and/or clopidogrel (Plavix) or ticlopidine (Ticlid). They excluded studies that evaluated patients with ST-segment elevation MI and studies using fibrinolytic drugs. Three reviewers independently abstracted the data from the studies. The final analysis included results from 7 studies enrolling a total of 8375 patients. Mortality was 5.4% over the 1month to 60 months follow-up of the studies. The authors used intention-to-treat analysis, since only 71% of patients assigned to invasive treatment actually received it, and 46% of patients in the conservative treatment group eventually underwent invasive treatment over the average 2 years of follow-up. Results were homogeneous and there was no evidence of publication bias. Mortality due to any cause, over an average of 2 years, was lower in the immediate invasive treatment group: 4.9% vs 6.5% (P = .001). Using immediate invasive treatment prevents 1 additional death for every 62 patients who receive it (95% CI, 42 - 154). This difference did not show up until more than 24 months of follow-up. Similarly, the rate of nonfatal MI was less with immediate intervention than with conservative treatment (number needed to treat [NNT] = 66; 39 - 275). This difference was not significant until more than 2 years of follow-up, but the rate did not increase in the short-term, either. Rates of hospitalization for recurrent unstable angina was lower with early invasive treatment and occurred in the first year (NNT = 11; 10-13).
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Barry, Henry, et al., editors. "Early Invasive Therapy Better for non-ST ACS." EE+ POEM Archive, John Wiley & Sons, 2019. Evidence Central, evidence.unboundmedicine.com/evidence/view/infoPOEMs/426395/all/Early_invasive_therapy_better_for_non_ST_ACS.
Early invasive therapy better for non-ST ACS. In: Barry HH, Ebell MHM, Shaughnessy AFA, et al, eds. EE+ POEM Archive. John Wiley & Sons; 2019. https://evidence.unboundmedicine.com/evidence/view/infoPOEMs/426395/all/Early_invasive_therapy_better_for_non_ST_ACS. Accessed March 24, 2023.
Early invasive therapy better for non-ST ACS. (2019). In Barry, H., Ebell, M. H., Shaughnessy, A. F., & Slawson, D. C. (Eds.), EE+ POEM Archive. John Wiley & Sons. https://evidence.unboundmedicine.com/evidence/view/infoPOEMs/426395/all/Early_invasive_therapy_better_for_non_ST_ACS
Early Invasive Therapy Better for non-ST ACS [Internet]. In: Barry HH, Ebell MHM, Shaughnessy AFA, Slawson DCD, editors. EE+ POEM Archive. John Wiley & Sons; 2019. [cited 2023 March 24]. Available from: https://evidence.unboundmedicine.com/evidence/view/infoPOEMs/426395/all/Early_invasive_therapy_better_for_non_ST_ACS.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Early invasive therapy better for non-ST ACS ID - 426395 ED - Barry,Henry, ED - Ebell,Mark H, ED - Shaughnessy,Allen F, ED - Slawson,David C, BT - EE+ POEM Archive UR - https://evidence.unboundmedicine.com/evidence/view/infoPOEMs/426395/all/Early_invasive_therapy_better_for_non_ST_ACS PB - John Wiley & Sons DB - Evidence Central DP - Unbound Medicine ER -