The First Medical Clinical College of Lanzhou University, Lanzhou, China.
Department of Cardiology, Emergency General Hospital, Beijing, China.
PLoS One. 2019 Aug 12;14(8):e0220847. doi: 10.1371/journal.pone.0220847. eCollection 2019.
An invasive approach is recommended as the treatment of patients with non-ST elevated acute coronary syndromes (NSTE-ACS). However, it remains unclear that the optimal time of angiography and intervention for patients with NSTE-ACS at present. This study was designed to compare the effect of early and delayed invasive strategies on short-medium term prognosis in patients with those.
Pubmed, Cochrane Library and Embase were searched up to Dec-30-2018. Randomized clinical trials comparing an early versus a delayed invasive strategy in patients with NSTE-ACS were included. The primary endpoint (all-cause death and recurrent myocardial infarction) and secondary endpoint (major bleeding and recurrent revascularization), as well as composite endpoint were assessed by random or fixed effected meta-analysis with software RevMan 5.3 version after short-medium term follow up.
A total of six randomized clinical trials involving 4,277 early or delayed invasive strategies patients with NSTE-ACS were included in the meta-analysis. Time to coronary angiography varied from 0.5 to 24 h in the early invasive strategy and from 18.6 to 72 h in the delayed invasive strategy. There was a statistical difference in the primary endpoint of all-cause death among patients with NSTE-ACS between early and delayed invasive strategies (4.6% vs 6%; OR:0.76; 95% CI:0.58 to 1.00; P = 0.05; I2 = 0%), but not for recurrent myocardial infarction (6.0% vs 6.3%; OR: 0.94; 95% CI: 0.55 to 1.61; P = 0.82; I2 = 60%). The major bleeding in patients with NSTE-ACS was similar between both invasive strategies (2.7% vs 3.1%; OR:0.88; 95% CI:0.59 to 1.31; P = 0.54; I2 = 0%). However, the composite endpoint in the early invasive strategy patients with NSTE-ACS was significantly lower than that of the delayed invasive strategy (10.9% vs 13.9%; OR:0.76; 95% CI:0.63 to 0.92; P = 0.006; I2 = 0%), and the recurrent revascularization between both strategies was just the opposite (8.7% vs 5.9%; OR:1.5; 95%CI:1.15 to 1.97; P = 0.003; I2 = 0%).
The systematic review and meta-analysis demonstrated that the early invasive strategy had a beneficial trend on all-cause death and significantly reduced the composite endpoint in patients with NSTE-ACS, but increased the rate of revascularization. These data could provide a solution for patients with those.
对于非 ST 段抬高型急性冠脉综合征（NSTE-ACS）患者，建议采用有创方法进行治疗。然而，目前对于 NSTE-ACS 患者进行血管造影和介入治疗的最佳时间仍不清楚。本研究旨在比较早期和延迟有创策略对这些患者的短期至中期预后的影响。
检索了 PubMed、Cochrane 图书馆和 Embase 数据库，截至 2018 年 12 月 30 日。纳入了比较 NSTE-ACS 患者早期与延迟有创策略的随机临床试验。通过随机或固定效应荟萃分析，使用 RevMan 5.3 软件评估短期至中期随访后的主要终点（全因死亡和复发性心肌梗死）和次要终点（主要出血和复发性血运重建）以及复合终点。
共纳入了 6 项涉及 4277 例 NSTE-ACS 患者早期或延迟有创策略的随机临床试验进行荟萃分析。早期有创策略的冠状动脉造影时间为 0.5 至 24 小时，延迟有创策略的冠状动脉造影时间为 18.6 至 72 小时。NSTE-ACS 患者的全因死亡主要终点在早期和延迟有创策略之间存在统计学差异（4.6%对 6%；OR：0.76；95%CI：0.58 至 1.00；P=0.05；I2=0%），但复发性心肌梗死无差异（6.0%对 6.3%；OR：0.94；95%CI：0.55 至 1.61；P=0.82；I2=60%）。NSTE-ACS 患者的主要出血在两种有创策略之间相似（2.7%对 3.1%；OR：0.88；95%CI：0.59 至 1.31；P=0.54；I2=0%）。然而，NSTE-ACS 患者的早期有创策略的复合终点显著低于延迟有创策略（10.9%对 13.9%；OR：0.76；95%CI：0.63 至 0.92；P=0.006；I2=0%），而两种策略之间的再次血运重建则相反（8.7%对 5.9%；OR：1.5；95%CI：1.15 至 1.97；P=0.003；I2=0%）。
系统评价和荟萃分析表明，早期有创策略对 NSTE-ACS 患者的全因死亡有获益趋势，并且显著降低了复合终点，但增加了血运重建的发生率。这些数据可能为这些患者提供了一种解决方案。
