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Management of Patients With NSTE-ACS and Prior CABG
Quick Takes
- The current study is a meta-analysis of RCTs (spanning 24 years) that compared the clinical benefit of invasive management against conservative management among patients with NSTE-ACS and prior CABG.
- There was no significant clinical benefit (all-cause mortality, cardiac mortality, MI, or cardiac-related hospitalization) of a routine invasive strategy over 2 years among patients with NSTE-ACS and history of prior CABG.
- Current results highlight the need for a dedicated RCT to help guide optimal treatment among patients with prior CABG.
Study Questions:
What is the benefit of a routine invasive strategy among patients with prior coronary artery bypass grafting (CABG) presenting with non–ST-elevation acute coronary syndrome (NSTE-ACS)?
Methods:
Eligible randomized controlled trials (RCTs) of routine invasive versus a conservative or selective invasive strategy in patients presenting with NSTE-ACS that included patients with previous CABG were included in this analysis. Outcomes assessed were all-cause mortality, cardiac mortality, myocardial infarction (MI), 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Summary data were obtained from 11 RCTs, including previously unpublished subgroup outcomes of nine trials, comprising 897 patients with previous CABG (477 routine invasive, 420 conservative/selective invasive) followed up for a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 (risk ratio [RR], 1.12; 95% confidence interval [CI], 0.97–1.29), cardiac mortality (RR, 1.05; 95% CI, 0.70–1.58), MI (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.
Perspective:
Current revascularization guidelines recommend invasive management of high-risk patients with NSTE-ACS. Prior CABG is considered a marker of ‘high risk’; however, data supporting the benefit of invasive management in prior CABG patients have been limited and come from observational data sets. The current study is a meta-analysis of RCTs (spanning 24 years) that compared clinical benefit of invasive management against conservative management among patients with NSTE-ACS and prior CABG. There was no significant clinical benefit (all-cause mortality, cardiac mortality, MI, or cardiac-related hospitalization) of a routine invasive strategy over 2 years among patients with NSTE-ACS and history of prior CABG. Current results are of interest and highlight the need for a dedicated RCT to help guide optimal treatment among patients with prior CABG.
Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Interventions and ACS
Keywords: Acute Coronary Syndrome, Coronary Artery Bypass
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