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Lookup NU author(s): Professor Vijay KunadianORCiD
This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).
© The Author(s) 2024.Background and Aims A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. Methods A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Results Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5–10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97–1.29), cardiac mortality (RR 1.05, 95% CI 0.70–1.58), myocardial infarction (RR 0.90, 95% CI 0.65–1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78–1.40). Conclusions This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.
Author(s): Kelham M, Vyas R, Ramaseshan R, Rathod K, de Winter RJ, de Winter RW, Bendz B, Thiele H, Hirlekar G, Morici N, Myat A, Michalis LK, Sanchis J, Kunadian V, Berry C, Mathur A, Jones DA
Publication type: Article
Publication status: Published
Journal: European Heart Journal
Year: 2024
Volume: 45
Issue: 27
Pages: 2380-2391
Print publication date: 14/07/2024
Online publication date: 28/05/2024
Acceptance date: 07/04/2024
Date deposited: 29/07/2024
ISSN (print): 0195-668X
ISSN (electronic): 1522-9645
Publisher: Oxford University Press
URL: https://doi.org/10.1093/eurheartj/ehae245
DOI: 10.1093/eurheartj/ehae245
Data Access Statement: Supplementary data are available at European Heart Journal online.
PubMed id: 38805681
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