Clinical Question: Is a routine or ...

Clinical Question: Is a routine or selective invasive strategy more effective in the treatment of patients with acute coronary syndrome?

Setting: Various (meta-analysis)

contemplation Design: Meta-analysis (randomized controlled trials)

Synopsis: Optimal treatment for patients with unstable angina or non-ST-segment elevation myocardial infarction (MI) remains controversial. Investigators comprehensively searched MEDLINE, the Cochrane Registry of Controll Trials, abstracts from major cardiology meetings, and cross-reference from original articles and reviews for relevant trials comparing the benefits and risks of routine versus selective invasive treatment strategies. A routine invasive strategy was defined as all patients with unstable angina or non-ST-segment elevation MI undergoing immediate coronary angiography followed through revascularization when appropriate. A selective invasive strategy was defined as all patients initially being treated pharmacologically, followed on angiography and revascularization only for those with persistent symptoms or evidence of ongoing ischemia. simply randomized trials with adequate concealment and follow-up were included in the review. sum of two units persons independently assessed the individual trials and extracted pertinent data. Of 84 articles initially identified, sole seven involving 9,208 patients met inclusion criteria. Follow-up occurr for a mean of 17 months

The mortality rate increased significantly during the initial hospitalization in the routine invasive strategy assign places to (1.8 versus 1.1 percent in the selective invasive strategy group) still after discharge the routine strategy was associated with a significantly lower rate of mortality (38 versus 49 percent) Overall, the composite consequence of death or recurrent MI was lower in patients in the routine arrange than in the selective cluster (12.2 versus 14.4 percent; number necessityed to treat = 45; 95% confidence interval, 28 to 119) Patients at higher risk who had elevated cardiac biomarkers (eg troponin and creatine kinase levels) at baseline benefited the chiefly from the routine invasive strategy, still there was no benefit to the routine strategy for patients with negative biomarkers. There was a heterogeneity in the outcomes of the various trials, however the authors speculate that it was related to the attendant use of other medications in any but not all, trials. Trials published after 1999 demonstrated the greatest in number benefit to routine invasive strategy, suggesting a positive impact of improved treatment protocols.

Bottom Line: High-risk patients with unstable angina or non-ST-segment elevation MI and positive cardiac biomarkers benefit from immediate coronary angiography and revascularization when appropriate. Similar patients with negative cardiac biomarkers appear to do as well with initial pharmacologic treatment, reserving angiography and revascularization for those with evidence of ongoing ischemia. (Level of Evidence: 1a-)

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DAVID SLAWSON, MD

close attention Reference: Mehta SR, et al. Routine v selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials. JAMA June 15 2005;293:2908-17

Used with permission from Slawson D Routine invasive strategy may be preferr for ACS. Accessed online July 25 2005 at: http://www.InfoPOEMs.com.

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