Non-ST-elevation acute coronary syndromes with previous coronary artery bypass grafting: a meta-analysis of invasive vs. conservative management

Author:

Kelham Matthew12ORCID,Vyas Rohan2,Ramaseshan Rohini12ORCID,Rathod Krishnaraj12ORCID,de Winter Robbert J3,de Winter Ruben W4,Bendz Bjorn5,Thiele Holger6ORCID,Hirlekar Geir7,Morici Nuccia8ORCID,Myat Aung9,Michalis Lampros K10,Sanchis Juan11ORCID,Kunadian Vijay12ORCID,Berry Colin13ORCID,Mathur Anthony1214ORCID,Jones Daniel A1214ORCID

Affiliation:

1. Centre for Cardiovascular Medicine and Devices, Faculty of Medicine & Dentistry, Queen Mary University of London , London , UK

2. Barts Interventional Group, Barts Heart Centre, Barts Health NHS Trust , West Smithfield, London , UK

3. Department of Cardiology Heart Center, Amsterdam UMC, Universiteit van Amsterdam , Amsterdam , The Netherlands

4. Department of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam , Amsterdam , The Netherlands

5. Department of Cardiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo , Oslo , Norway

6. Heart Center Leipzig at University of Leipzig and Leipzig Heart Science , Leipzig , Germany

7. Department of Cardiology, Sahlgrenska University Hospital , Gothenburg , Sweden

8. IRCCS S. Maria Nascente—Fondazione Don Carlo Gnocchi ONLUS , Milan , Italy

9. Medical Director (Cardiology), Medpace UK , London , UK

10. 2nd Department of Cardiology, Faculty of Medicine, School of Health Sciences, University of Ioannina and University Hospital of Ioannina , University Campus, Ioannina 45110 , Greece

11. Cardiology Department, University Clinic Hospital of València, INCLIVA University of València, CIBER CV , València , Spain

12. Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust and Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University , Newcastle upon Tyne , UK

13. British Heart Foundation Cardiovascular Research Centre, University of Glasgow , Glasgow , UK

14. NIHR Barts Biomedical Research Centre, Queen Mary University of London , Charterhouse Square, London , UK

Abstract

Abstract Background and Aims A routine invasive strategy is recommended in the management of higher risk patients with non-ST-elevation acute coronary syndromes (NSTE-ACSs). However, patients with previous coronary artery bypass graft (CABG) surgery were excluded from key trials that informed these guidelines. Thus, the benefit of a routine invasive strategy is less certain in this specific subgroup. Methods A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted. A comprehensive search was performed of PubMed, EMBASE, Cochrane, and ClinicalTrials.gov. Eligible studies were RCTs of routine invasive vs. a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG. Summary data were collected from the authors of each trial if not previously published. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction, and cardiac-related hospitalization. Using a random-effects model, risk ratios (RRs) with 95% confidence intervals (CIs) were calculated. Results Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a weighted mean of 2.0 (range 0.5–10) years. A routine invasive strategy did not reduce all-cause mortality (RR 1.12, 95% CI 0.97–1.29), cardiac mortality (RR 1.05, 95% CI 0.70–1.58), myocardial infarction (RR 0.90, 95% CI 0.65–1.23), or cardiac-related hospitalization (RR 1.05, 95% CI 0.78–1.40). Conclusions This is the first meta-analysis assessing the effect of a routine invasive strategy in patients with prior CABG who present with NSTE-ACS. The results confirm the under-representation of this patient group in RCTs of invasive management in NSTE-ACS and suggest that there is no benefit to a routine invasive strategy compared to a conservative approach with regard to major adverse cardiac events. These findings should be validated in an adequately powered RCT.

Publisher

Oxford University Press (OUP)

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