医学
急性冠脉综合征
危险系数
荟萃分析
内科学
临床试验
随机对照试验
置信区间
心肌梗塞
作者
Alexander Jobs,Shamir R. Mehta,Gilles Montalescot,Éric Vicaut,Arnoud W.J. van’t Hof,Erik A Badings,Franz–Josef Neumann,Adnan Kastrati,Alessandro Sciahbasi,Paul‐Georges Reuter,Frédéric Lapostolle,Aleksandar Milošević,Goran Stanković,Dejan Milašinović,Reinhard Vonthein,Steffen Desch,Holger Thiele
出处
期刊:The Lancet
[Elsevier]
日期:2017-08-01
卷期号:390 (10096): 737-746
被引量:163
标识
DOI:10.1016/s0140-6736(17)31490-3
摘要
Background A 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. Methods We 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). Findings We 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. Interpretation An 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. Funding None.
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