Timing of Coronary Invasive Strategy inNon-ST-Segment Elevation Acute Coronary Syndromes and Clinical Outcomes: An Updated Meta-Analysis.

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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 thepublished 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; I2= 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; I2=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; I2= 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 standardizedmean difference-0.40; 95% CI:-0.59 to-0.21; p< 0.01; I2= 79%). Major bleeding was similar in the 2groups (3.9% vs. 4.2%; random-effects OR: 0.94; 95% CI: 0.73 to 1.22; p= 0.64; I2= 0%). An early invasive strategy does not reduce the risk for death or myocardial infarction compared with adelayed strategy. Recurrent ischemia and length of stay were significantly reduced with an early invasive strategy.