Hoenig M R, Doust J A, Aroney C N, Scott I A
Centre for Research in Vascular Biology, Australian Institute for Bioengineering and Nanotechnology, University of Queensland, Brisbane, QLD, Australia 4072.
Cochrane Database Syst Rev. 2006 Jul 19(3):CD004815. doi: 10.1002/14651858.CD004815.pub2.
In patients with unstable angina and non-ST-elevation myocardial infarction (UA/NSTEMI) two strategies are possible: a routine invasive strategy where all patients undergo coronary angiography shortly after admission and, if indicated, coronary revascularization; or a conservative strategy where medical therapy alone is used initially with selection of patients for angiography based on clinical symptoms or investigational evidence of persistent myocardial ischemia.
To determine the benefits of an invasive compared to a conservative strategy for treating UA/NSTEMI in the stent era.
The Cochrane Central Register of Controlled Trials (Issue 3 2005), MEDLINE and EMBASE were searched from 1996 to September 2005 with no language restrictions.
Included studies were prospective trials comparing invasive with conservative strategies in UA/NSTEMI.
We identified 5 studies (7818 participants). Using intention-to-treat analysis with random effects models, summary estimates of relative risk (95% confidence interval [CI]) were determined for primary end-points of all-cause death, fatal and non-fatal myocardial infarction; all-cause death or non-fatal myocardial infarction; and refractory angina. Further analysis of included studies was undertaken based on whether glycoprotein IIb/IIIa receptor antagonists were used routinely. Heterogeneity was assessed using chi-square and variance (I(2)) methods.
In the all-study analysis, mortality during initial hospitalization showed a trend to hazard with an invasive strategy; relative risk 1.59 (95% CI 0.96 to 2.64). Mortality and myocardial infarction assessed at 2-5 years in two trials were significantly decreased by an invasive strategy with relative risk of 0.75 (95% CI 0.62 to 0.92) and 0.75 (95% CI 0.61 to 0.91) respectively. The composite end-point of death or non-fatal myocardial infarction was significantly decreased by an invasive strategy at several time points after initial hospitalization. The incidence of early (<4 months) and intermediate (6-12 months) refractory angina were both significantly decreased by an invasive strategy; relative risk 0.47 (95% CI 0.32 to 0.68) and 0.67 (95% CI 0.55 to 0.83) respectively, as were early and intermediate rehospitalization rates with relative risk 0.60 (95% CI 0.41 to 0.88) and 0.67 (95% CI 0.61 to 0.74) respectively. The invasive strategy was associated with a two-fold increase in the relative risk of peri-procedural myocardial infarction (as variably defined) and a 1.7-fold increase in the relative risk of bleeding.
AUTHORS' CONCLUSIONS: An early invasive strategy is preferable to a conservative strategy in the treatment of UA/NSTEMI.
对于不稳定型心绞痛和非ST段抬高型心肌梗死（UA/NSTEMI）患者，有两种治疗策略可供选择：一种是常规侵入性策略，即所有患者在入院后不久即接受冠状动脉造影，如有指征则进行冠状动脉血运重建；另一种是保守策略，即最初仅采用药物治疗，根据临床症状或持续性心肌缺血的检查证据选择患者进行造影。
确定在支架时代，侵入性策略与保守策略治疗UA/NSTEMI相比的益处。
检索了Cochrane对照试验中心注册库（2005年第3期）、MEDLINE和EMBASE，检索时间从1996年至2005年9月，无语言限制。
纳入的研究为比较UA/NSTEMI侵入性策略与保守策略的前瞻性试验。
我们确定了5项研究（7818名参与者）。采用意向性分析和随机效应模型，确定全因死亡、致命性和非致命性心肌梗死；全因死亡或非致命性心肌梗死；以及难治性心绞痛等主要终点的相对危险度（95%置信区间[CI]）的汇总估计值。根据是否常规使用糖蛋白IIb/IIIa受体拮抗剂对纳入研究进行进一步分析。使用卡方检验和方差（I²）方法评估异质性。
在所有研究的分析中，初始住院期间的死亡率显示侵入性策略有增加风险的趋势；相对危险度为1.59（95%CI 0.96至2.64）。两项试验中在2至5年评估的死亡率和心肌梗死发生率，侵入性策略使其显著降低，相对危险度分别为0.75（95%CI 0.62至0.92）和0.75（95%CI 0.61至0.91）。侵入性策略使初始住院后几个时间点的死亡或非致命性心肌梗死复合终点显著降低。侵入性策略使早期（<4个月）和中期（6至12个月）难治性心绞痛的发生率均显著降低；相对危险度分别为0.47（95%CI 0.32至0.68）和0.67（95%CI 0.55至0.83），早期和中期再住院率也显著降低，相对危险度分别为0.60（95%CI 0.41至0.88）和0.67（95%CI 0.61至0.74）。侵入性策略与围手术期心肌梗死（定义不同）的相对危险度增加两倍以及出血的相对危险度增加1.7倍相关。
在治疗UA/NSTEMI时，早期侵入性策略优于保守策略。
