0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review |

Early Invasive vs Conservative Treatment Strategies in Women and Men With Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction:  A Meta-analysis

Michelle O’Donoghue, MD; William E. Boden, MD; Eugene Braunwald, MD; Christopher P. Cannon, MD; Tim C. Clayton, MSc; Robbert J. de Winter, MD, PhD; Keith A. A. Fox, MB, ChB; Bo Lagerqvist, MD, PhD; Peter A. McCullough, MD, MPH; Sabina A. Murphy, MPH; Rudolf Spacek, MD, PhD; Eva Swahn, MD, PhD; Lars Wallentin, MD, PhD; Fons Windhausen, MD; Marc S. Sabatine, MD, MPH
JAMA. 2008;300(1):71-80. doi:10.1001/jama.300.1.71.
Text Size: A A A
Published online

Context Although an invasive strategy is frequently used in patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.

Objective To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS.

Data Sources Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.

Study Selection Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.

Data Extraction The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.

Data Synthesis Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).

Conclusions In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.

Figures in this Article

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Figures

Place holder to copy figure label and caption
Figure 1. Selection of Randomized Clinical Trials for Inclusion in Meta-analysis
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2. Death, MI, or Rehospitalization With ACS in Trials of an Invasive vs Conservative Treatment Strategy in NSTE ACS
Graphic Jump Location

ACS indicates acute coronary syndromes; CI, confidence interval; MI, myocardial infarction; NSTE, non–ST-segment elevation. Size of data markers is weighted based on the inverse variance.

Place holder to copy figure label and caption
Figure 3. Death or Nonfatal MI for Index Hospitalization and Hospital Discharge to End of 12 Months of Follow-up in Trials of an Invasive vs Conservative Treatment Strategy in NSTE ACS
Graphic Jump Location

CI indicates confidence interval; MI, myocardial infarction; NSTE ACS, non–ST-segment elevation acute coronary syndromes. Odds ratios were generated from random-effects models. Size of data markers is weighted based on the inverse variance.

Place holder to copy figure label and caption
Figure 4. Death, MI, or Rehospitalization With ACS for Biomarker Status and ST-Segment Deviation in Trials of an Invasive vs Conservative Treatment Strategy in NSTE ACS
Graphic Jump Location

ACS indicates acute coronary syndromes; CI, confidence interval; MI, myocardial infarction; NSTE, non–ST-segment elevation. Odds ratios were generated from random-effects models. Size of data markers is weighted based on the inverse variance. The odds ratios (ORs) and corresponding P values for the interaction terms for the efficacy of an invasive over a conservative strategy in biomarker-positive vs biomarker-negative patients were as follows: for all patients, OR for interaction, 0.79; P for interaction = .18; for women, OR for interaction, 0.75; P for interaction = .36; and for men, OR for interaction, 0.77; P for interaction = .09. The analogous data for patients with vs without ST-segment deviation were as follows: for all patients, OR for interaction, 0.83; P for interaction = .07; for women, OR for interaction, 0.87; P for interaction = .76; and for men, OR for interaction, 0.79; P for interaction = .07. VINO,20 VANQWISH,18 and ICTUS8 trials were excluded from the primary biomarker analysis because they only enrolled patients with elevated biomarkers thus precluding the comparison of biomarker-positive and biomarker-negative subgroups. The meta-analysis OR and 95% CIs for the efficacy of an invasive strategy vs conservative strategy if those 3 trials were also included were as follows: for all patients biomarker-positive, OR, 0.72; 95% CI, 0.53-0.98; for all patients biomarker-negative, OR, 0.79; 95% CI, 0.60-1.03; for biomarker-positive men, OR, 0.71; 95% CI, 0.49-1.01; for biomarker-negative men, OR, 0.72; 95% CI, 0.54-0.98; for biomarker-positive women, OR, 0.71; 95% CI, 0.56-0.91; and for biomarker-negative women, OR, 0.94; 95% CI, 0.61-1.44.

Tables

References

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.

Multimedia

Some tools below are only available to our subscribers or users with an online account.

3,517 Views
117 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles
Jobs
JAMAevidence.com

Users' Guides to the Medical Literature
The Number Needed to Treat in Weighing Benefit and Harm

×
brightcove.createExperiences();