University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck, Germany; German Centre for Cardiovascular Research, Lübeck, Germany.
Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
Lancet. 2017 Aug 19;390(10096):737-746. doi: 10.1016/S0140-6736(17)31490-3. Epub 2017 Aug 1.
A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality.
We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988).
We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive.
An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients.
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对于非 ST 段抬高型急性冠脉综合征（NSTE-ACS）患者，建议采用常规有创策略。然而，最佳有创策略时机仍不明确。个别临床试验在检测死亡率获益方面能力不足；因此，我们进行了一项荟萃分析以评估时机对死亡率的影响。
我们通过检索 MEDLINE、Cochrane 对照试验中心注册库和 Embase，确定了比较 NSTE-ACS 患者早期与延迟有创策略的随机对照试验。我们纳入了报告至少 30 天住院随机分组后全因死亡率的试验，并与试验研究者达成合作（即提供个体患者数据或标准化表格数据）。我们使用随机效应模型汇总危险比（HR）。该荟萃分析已在 PROSPERO（CRD42015018988）注册。
我们纳入了 8 项试验（n=5324 例患者），中位随访时间为 180 天（IQR 180-360）。总体而言，早期有创组与延迟有创组相比死亡率无显著降低（HR 0·81，95%CI 0·64-1·03；p=0·0879）。在高危患者的预设分析中，我们发现基线时心脏标志物升高（HR 0·761，95%CI 0·581-0·996）、合并糖尿病（0·67，0·45-0·99）、GRACE 风险评分＞140（0·70，0·52-0·95）和年龄＞75 岁（0·65，0·46-0·93）的患者采用早期有创策略可降低死亡率，尽管交互检验不确定。
对于所有 NSTE-ACS 患者，早期有创策略与延迟有创策略相比并未降低死亡率。然而，早期有创策略可能降低高危患者的死亡率。
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