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Early invasive versus early conservative strategy in the management of unstable angina and non-Q wave MI: A meta-analysis.


Benedict M Lazatin,
Federick C Cheng,
Marilou T De Jesus

Related Institution

Heart Institute - St. Luke's Medical Center

Publication Information

Publication Type
Publication Sub Type
Philippine Journal of Cardiology
Publication Date
April-June 2003


BACKGROUND: Unstable angina and non-Q wave myocardial infarction are increasingly common syndromes in clinical practice. Over the past years, there have been several large randomized trials, most of them including over 1000 patients and using modern baseline treatment with aspirin, unfractionated or low-molecular weight heparin, and recently glycoprotein IIb/IIIa inhibition and stenting. But despite all the advances, there is continued debate as to whether a routine, early invasive strategy involving coronary angiography followed by revascularization in suitable patients is superior to a conservative approach of maximum medical management and performance of coronary angiography / revascularization only when clinically indicated. This meta-analysis is undertaken to determine whether an early invasive or an early conservative strategy is better in the management of unstable angina and non-Q wave myocardial infarction.

METHODS: This is a meta-analysis (odds ratio, confidence interval). The studies were identified by Medline search and from the Cochrane database from 1990-2002 using the following MeSH terms: unstable angina, non-Q wave myocardial infarction, treatment, invasive and conservative, and by reviewing reference lists and inquiring from experts, pharmaceutical companies and from Cardiology websites.

RESULTS: Six randomized controlled trials were included in this meta-analysis namely: Thrombolysis in Myocardial Infarction (TIMI) IIIB, Veterans Affair Non-Q wave Infarction Strategies in Hospital (VANQWISH) trial, Fast Revascularization during Instability in Coronary Artery Disease (FRISC II), Randomized Intervention Treatment of Angina (RITA 3) trial, Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS-TIMI 18) trial and Value of First Day Coronary Angiography/Angioplasty in Evolving Non-ST Elevation Myocardial Infarction (VINO). Measurement of primary endpoints of myocardial infarction, death and myocardial infarction and/ or death were done with the combined Peto odds ratio as follows: 0.76 (0.65-0.89) for myocardial infarction, 0.97 (0.80-1.18) for death, and 0.84 (0.74-0.96) for MI and/or death. Hospital readmission was used as a secondary endpoint with OR of 0.57 (0.50.064).

CONCLUSION: The meta-analysis of these studies demonstrated a reduction in the primary endpoints of myocardial infarction and death and/or myocardial infarction in the early invasive group. Readmission was likewise significantly lower with the invasive group. (Author)


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