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Invasive therapy along with glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival in non–ST-segment elevation acute coronary syndromes: a meta-analysis and review of the literature

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Abstract

Current evidence suggests that routine invasive therapy in the setting of unstable angina/non–ST-segment elevation myocardial infarction (UA/NSTEMI) reduces the incidence of composite end points (i.e., death, myocardial infarction, or angina.). The 2002 American College of Cardiology/American Heart Association guidelines recommend invasive therapy in high-risk patients, although it is unknown if such an approach improves survival. We conducted a meta-analysis on 5 studies in 6,766 UA/NSTEMI patients who were randomized to either routine invasive versus conservative therapy in the era of glycoprotein IIb/IIIa inhibitors and intracoronary stents. Compared with conservative therapy, an invasive approach suggested a reduction in mortality at 6 to 12 months (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.63 to 1.03) and at 24 months (RR 0.77, 95% CI 0.60 to 0.99). The composite end point of death or myocardial infarction was reduced throughout all periods of follow-up: at 30 days (RR 0.61, 95% CI 0.45 to 0.84), at 6 months (RR 0.75, 95% CI 0.63 to 0.89), and at 12 months (RR 0.78, 95% CI 0.65 to 0.92). For the same composite end point at 6 to 12 months, men benefited from invasive therapy (RR 0.68, 95% CI 0.57 to 0.81), as did troponin-positive patients (RR 0.74, 95% CI 0.59 to 0.94). The results for women (RR 1.07, 95% CI 0.82 to 1.41) and troponin-negative patients (RR 0.82, 95% CI 0.59 to 1.14) were equivocal. Routine invasive therapy in UA/NSTEMI patients along with adjunctive use of glycoprotein IIb/IIIa inhibitors and intracoronary stents improves survival. Enhanced risk stratification is needed in women and troponin-negative patients so that invasive therapy may be more effectively recommended in these groups.

Section snippets

Literature review

We searched the MEDLINE, EMBASE, CRISP, metaRegister of Controlled Trials, and Cochrane databases for randomized clinical trials from 1990 through 2003 using the Medical Subject Heading terms “angina, unstable,” “myocardial infarction,” “angioplasty, transluminal, percutaneous coronary,” “stents,” and “platelet glycoprotein glycoprotein IIb/IIIa complex.” We also hand-searched relevant journals, corresponded with investigators and experts in the field, and used the Science Citation Index to

Baseline characteristics

The characteristics of the 5 studies that were included in the meta-analysis are listed in Table 1. In all, 6,766 patients were enrolled from June 1996 until March 2000 from many North American and European countries. Of these, 3,371 were randomized to the invasive arm and 3,395 to the conservative therapy arm. The baseline characteristics of patients randomized to invasive and conservative therapies were similar within each study. The median ages of participants ranged from 61 to 66 years. The

Discussion

Our meta-analysis suggests a trend toward a 20% reduction in 6- to 12-month mortality in UA/NSTEMI patients randomized to a routine invasive approach. There was no obvious difference in 1-month mortality between invasive and conservative management, but 2-year mortality was reduced 23% with invasive therapy. The composite end point of death or MI was significantly reduced throughout all follow-up periods. Sex differences were apparent, with a clear reduction in death or MI at 6 to 12 months in

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