Comparison of invasive treatment strategies in patients with non–ST elevation acute coronary syndrome: A systematic review and meta-analysis

Abstract

Abstract Objective To compare the mortality associated with percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in patients with non ST-elevation acute coronary syndrome (NSTE-ACS). Methods We searched publications from PubMed, Embase, Web of Science, Cochrane Library from inception until December 23, 2020. All randomized clinical trials (RCTs) and observational studies comparing all-cause mortality after treatment with CABG versus PCI for patients with NSTE-ACS with minimum follow-up length of 6 months were included. Restricted mean survival time (RMST) difference from RCTs and adjusted RMST differences from observational studies were computed by reconstructing time-to-event data from published Kaplan-Meier curves. Extracted hazard ratio (HRs) were also assessed as secondary analyses. Results Our systematic review included one individual participant data analysis of three RCTs and 8 observational studies. A meta-regression showed a significant association between log-transformed HRs and studies’ follow-up lengths (-0.009 [-0.002, -0.016] log-HR per one year longer study follow-up period, P=0.037), suggesting the violation the proportional hazard assumption. Analysis on 6 studies with available RMST data showed a significant inverse association between adjusted RMST differences and cutoff years (slope: -0.028 [-0.042, -0.013] year difference per one year longer cutoff, P Conclusion There was a trend toward the benefit of CABG compared with PCI in the longer follow-up in patients with NSTE-ACS. A large, well designed RCT with longer follow-up is needed to obtain definitive evidence on this topic.