Medicine by the Numbers

A Collaboration of and AFP

Early Invasive Management of Acute Coronary Syndromes


Am Fam Physician. 2018 Dec 1;98(11):online.


Details for This Review

Study Population: Patients with unstable angina or acute non–ST-segment elevation myocardial infarction (NSTEMI)

Efficacy End Points: Death, myocardial infarction, angina symptoms, and rehospitalization at six- to 12-month follow-up

Harm End Points: Bleeding, periprocedural myocardial infarction, death

Narrative: Reperfusion therapy for acute ST-segment elevation myocardial infarction (STEMI) has been shown to be beneficial. However, there is controversy regarding the management of unstable angina and NSTEMI. Fowler and Conti coined the term unstable angina in 1971 for patients who did not meet the criteria for acute myocardial infarction or stable angina.1,2 The term may be outdated now with the increased sensitivity of cardiac troponins. Patients with unstable angina or patients in the “gray zone” of symptomatic ischemia can now be diagnosed as having NSTEMI.3 This Cochrane review4 updates the 2010 review5 of early invasive management for acute coronary syndrome that identifed five trials. That systematic review found a statistically significant reduction in myocardial infarction (2%) with the invasive strategy and concluded that an early invasive strategy was superior to a noninvasive strategy.5

In this updated Cochrane review,4 the authors added three new trials with a total of 1,099 participants to the meta-analysis. Therefore, the updated Cochrane review represents eight randomized controlled trials with a total of 8,915 participants randomized to an invasive strategy, whereby all patients undergo coronary angiography and revascularization (as necessary), or a conservative strategy in which medical therapy is used initially and patients are selected for cardiac catheterization only if there is evidence of persistent myocardial ischemia. Patients included in the studies were at least 18 years of age, had an episode of chest pain at rest, and had at least one of the following criteria: (1) electrocardiography changes including new ST depression, transient ST elevation (less than 20 minutes), or ischemic T wave inversions in at least two contiguous leads; (2) elevated cardiac markers; or (3) known coronary artery disease. Patients were excluded if they had persistent ST elevation, secondary causes of acute myocardial ischemia or cardiac biomarker elevations, severe cardiogenic shock or congestive heart failure, arrhythmias that required catheterization, refractory symptoms, coronary revascularization within the past 30 days, or intolerance to anticoagulation or antiplatelet therapy.

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Author disclosure: No relevant financial affiliations.

Copyright © 2018 MD Aware, LLC ( Used with permission.

This series is coordinated by Dean A. Seehusen, MD, MPH, AFP Assistant Medical Editor, and Daniel Runde, MD, from the NNT Group.

A collection of Medicine by the Numbers published in AFP is available at


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2. Conti CR, Greene B, Pitt B, et al. Coronary surgery in unstable angina pectoris [abstract]. Circulation. 1971;44(suppl II):II-154.

3. Braunwald E, Morrow DA. Unstable angina: is it time for a requiem? Circulation. 2013;127(24):2452–2457.

4. Fanning JP, Nyong J, Scott IA, Aroney CN, Walters DL. Routine invasive strategies versus selective invasive strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2016;(5):CD004815.

5. Hoenig MR, Aroney CN, Scott IA. Early invasive versus conservative strategies for unstable angina and non-ST elevation myocardial infarction in the stent era. Cochrane Database Syst Rev. 2010;(3):CD004815.

6. Savonitto S, Cavallini C, Petronio AS, et al. Early aggressive versus initially conservative treatment in elderly patients with non-ST-segment elevation acute coronary syndrome: a randomized controlled trial. JACC Cardiovasc Interv. 2012;5(9):906–916.

7. Savonitto S, De Servi S, Petronio AS, et al. Early aggressive vs. initially conservative treatment in elderly patients with non-ST-elevation acute coronary syndrome: the Italian Elderly ACS study. J Cardiovasc Med (Hagerstown). 2008;9(3):217–226.

8. Thiele H, Rach J, Klein N, et al. Optimal timing of invasive angiography in stable non-ST-elevation myocardial infarction: the Leipzig Immediate versus early and late percutaneous coronary intervertion trial in NSTEMI (LIPSIA-NSTEMI Trial). Eur Heart J. 2012;33(16):2035–2043.



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