Comparison of early and delayed invasive strategies in short-medium term among patients with non-ST segment elevation acute coronary syndrome: A systematic review and meta-analysis

Background and objectives: 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. Methods: 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. Result: 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%). Conclusion: 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.