Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; Aix-Marseille Université, INSERM UMR-S 1076, Vascular Research Center of Marseille, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France.
Service de Cardiologie, Centre Hospitalier Universitaire de Marseille, Hôpital Nord, Aix-Marseille Université, Marseille, France; MARS Cardio, Mediterranean Association for Research and Studies in Cardiology, Hôpital Nord, Marseille, France.
JACC Cardiovasc Interv. 2016 Nov 28;9(22):2267-2276. doi: 10.1016/j.jcin.2016.09.017.
The aim of this study was to compare an early versus a delayed invasive strategy in non-ST-segment elevation acute coronary syndromes by performing a meta-analysis of all available randomized controlled clinical trials.
An invasive approach is recommended to prevent death and myocardial infarction in non-ST-segment elevation acute coronary syndromes. However, the timing of angiography and the subsequent intervention, when required, remains controversial.
A previous meta-analysis of 7 randomized clinical trials comparing early and delayed invasive strategies in non-ST-segment elevation acute coronary syndromes with 3 new randomized clinical trials identified in a search of the published research (n = 10 trials, n = 6,397 patients) was updated.
The median time between randomization and angiography ranged from 0.5 to 14.0 h in the early group and from 18.3 to 86.0 h in the delayed group. There was no difference in the primary endpoint of mortality (4% vs. 4.7%; random-effects odds ratio [OR]: 0.85; 95% confidence interval [CI]: 0.67 to 1.09; p = 0.20; I = 0%). The rate of myocardial infarction was also similar (6.7% vs. 7.7%; random-effects OR: 0.88; 95% CI: 0.53 to 1.45; p = 0.62; I = 77.5%). An early strategy was associated with a reduction in recurrent ischemia or refractory angina (3.8% vs. 5.8%; random-effects OR: 0.54; 95% CI: 0.40 to 0.74; p < 0.01; I = 28%) and a shorter in-hospital stay (median 112 h [interquartile range: 61 to 158 h] vs. 168 h [interquartile range: 90.3 to 192 h]; random-effects standardized mean difference -0.40; 95% CI: -0.59 to -0.21; p < 0.01; I = 79%). Major bleeding was similar in the 2 groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p = 0.64; I = 0%).
An early invasive strategy does not reduce the risk for death or myocardial infarction compared with a delayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.
本研究旨在通过对所有可用的随机对照临床试验进行荟萃分析，比较非 ST 段抬高型急性冠状动脉综合征的早期与延迟侵入性策略。
推荐采用侵入性方法预防非 ST 段抬高型急性冠状动脉综合征患者的死亡和心肌梗死。然而，血管造影术的时机和随后需要进行的介入治疗仍存在争议。
对先前的荟萃分析进行了更新，该分析纳入了 7 项比较非 ST 段抬高型急性冠状动脉综合征早期和延迟侵入性策略的随机临床试验，并新增了在已发表研究中检索到的 3 项新的随机临床试验（n=10 项试验，n=6397 例患者）。
早期组和延迟组的随机分组至血管造影术的中位时间分别为 0.5 至 14.0 小时和 18.3 至 86.0 小时。主要终点死亡率无差异（4%比 4.7%；随机效应比值比[OR]：0.85；95%置信区间[CI]：0.67 至 1.09；p=0.20；I=0%）。心肌梗死发生率也相似（6.7%比 7.7%；随机效应 OR：0.88；95% CI：0.53 至 1.45；p=0.62；I=77.5%）。早期策略与复发性缺血或难治性心绞痛的减少相关（3.8%比 5.8%；随机效应 OR：0.54；95% CI：0.40 至 0.74；p<0.01；I=28%），且住院时间更短（中位数 112 小时[四分位距：61 至 158 小时]比 168 小时[四分位距：90.3 至 192 小时]；随机效应标准化均数差-0.40；95% CI：-0.59 至-0.21；p<0.01；I=79%）。两组大出血发生率相似（3.9%比 4.2%；随机效应 OR：0.94；95% CI：0.73 至 1.22；p=0.64；I=0%）。
与延迟策略相比，早期侵入性策略并不能降低死亡或心肌梗死的风险。早期侵入性策略可显著减少复发性缺血和住院时间。
