Meta-Analysis of Randomized Trials of Long-Term All-Cause Mortality in Patients With Non–ST-Elevation Acute Coronary Syndrome Managed With Routine Invasive Versus Selective Invasive Strategies

Randomized trials and meta-analyses demonstrated that a routine invasive strategy improves outcomes in patients with non–ST-elevation acute coronary syndrome (NSTE-ACS) compared to a selective invasive strategy. Benefit was driven primarily by a reduction in the risk of myocardial infarction. However, the impact of either strategy on long-term mortality is unknown. Trials that compared a routine invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and reported data on all-cause mortality ≥1 year were included. Summary odds ratios (OR) were constructed using Peto's model for all-cause mortality using the longest available follow-up data. Subgroup analysis was performed for follow-up at 1 to ≤5 years and >5 years. Eight trials with 6,657 patients were available for analysis. At a mean of 10.3 years, the risk of all-cause mortality was similar with both strategies (28.5% vs 28.5%; OR 1.00, 95% confidence interval [CI] 0.90 to 1.12, p = 0.97). This effect was similar on subgroup analysis for follow-up at 1 to ≤5 years (OR 0.89, 95% CI 0.77 to 1.04, p = 0.15) and >5 years (OR 1.02, 95% CI 0.90 to 1.14, p = 0.79). There was no difference in treatment effect across various study-level covariates such as age, gender, diabetes, and positive troponin (all P for interaction >0.05). In conclusion, in patients with NSTE-ACS, both routine invasive and selective invasive strategies have a similar risk of all-cause mortality at ∼10 years. This illustrates there are still opportunities to change the trajectory of mortality events among invasively treated patients with NSTE-ACS.