• Alexander Jobs, Shamir R Mehta, Gilles Montalescot, Eric Vicaut, Van't Hof Arnoud W J AWJ Department of Cardiology, Isala Klinieken, Zwolle, Netherlands; Department of Cardiology Research, Deventer Hospital, Deventer, Netherlands., Erik A Badings, Franz-Josef Neumann, Adnan Kastrati, Alessandro Sciahbasi, Paul-Georges Reuter, Frédéric Lapostolle, Aleksandra Milosevic, Goran Stankovic, Dejan Milasinovic, Reinhard Vonthein, Steffen Desch, and Holger Thiele.
• University Heart Center Lübeck, Medical Clinic II, Department of Cardiology, Angiology and Intensive Care Medicine, Lübeck, Germany; German Centre for Cardiovascular Research, Lübeck, Germany.
• Lancet. 2017 Aug 19; 390 (10096): 737-746.

BackgroundA routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality.MethodsWe identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988).FindingsWe included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive.InterpretationAn early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients.FundingNone.Copyright © 2017 Elsevier Ltd. All rights reserved.

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