Is an invasive strategy (urgent coronary angiography followed by revascularization, if appropriate) the best treatment for women and men with non-ST-segment elevation acute coronary syndromes?

Overall evidence from this meta-analysis supports the benefit of an invasive treatment strategy for men and high-risk women with non-ST-segment elevation acute coronary syndromes. No significant benefit was found favoring an invasive strategy over conservative treatment for low-risk women. (LOE = 1a-)

O'Donoghue M, Boden WE, Braunwald E, et al. Early invasive vs conservative treatment strategies in women and men with unstable angina and non-ST-segment elevation myocardial infarction. A meta-analysis. JAMA 2008;300(1):71-80.  [PMID:18594042]

Meta-analysis (randomized controlled trials)

Government

Various (meta-analysis)

The optimal treatment of women with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is uncertain. These investigators searched MEDLINE, the Cochrane Registry, and major conference abstracts, and contacted experts in the field for randomized trials comparing an invasive treatment strategy with a conservative treatment strategy for adults presenting with NSTE ACS. An invasive strategy consisted of urgent referral for coronary angiography followed by revascularization when appropriate. A conservative strategy relied primarily on medical management with coronary angiography only for patients with recurrent symptomatic ischemia or inducible ischemia on subsequent noninvasive testing. The authors do not specifically state whether an independent search and individual study evaluation occurred by more than one person. A total of 8 trials enrolling 3075 women and 7075 men met study eligibility criteria. An invasive strategy significantly reduced the composite risk of death, myocardial infarction, or rehospitalization compared with conservative treatment (21.2% vs 26.3%, respectively; number needed to treat [NNT] = 20; 95% CI, 14-32) in men but not in women. However, among women with elevated biomarkers (creatine kinase MB or troponin), an invasive strategy significantly reduced the composite risk of death, myocardial infarction, or rehospitalization compared with conservative treatment (21.5% vs 28.4%; NNT= 15; 8-56). The results of the individual trials were heterogeneous (some favored one or the other strategy) and the authors did not report a formal assessment for publication bias.