EBQ:Routine vs an Invasive strategy in ACS - Revision history

Danbot: Rename Outcomes via Meta-Analysis to Outcomes for EBQ format consistency

2026-03-22T06:10:52Z

Rename Outcomes via Meta-Analysis to Outcomes for EBQ format consistency

← Older revision		Revision as of 06:10, 22 March 2026
Line 55:		Line 55:
	*Conservative (selective invasive) strategy: medical management with angiography only for recurrent or refractory ischemia, hemodynamic instability, or positive stress test		*Conservative (selective invasive) strategy: medical management with angiography only for recurrent or refractory ischemia, hemodynamic instability, or positive stress test

	==Outcomes ~~via Meta-Analysis~~==		==Outcomes==
	N=4608		N=4608
	===In Hospital Hazards Outcomes===		===In Hospital Hazards Outcomes===

Danbot: Added Population, Interventions, Criticisms, and Funding sections

2026-03-21T22:46:55Z

Added Population, Interventions, Criticisms, and Funding sections

@@ Line 31: / Line 31: @@
 *'''A selective invasive strategy (also referred to as a conservative or noninvasive strategy) was defined as an approach to patients who were initially treated with pharmacological therapy, after which cardiac catheterization and revascularization was performed only for those with recurrent symptoms.'''
 *'''A routine invasive strategy was defined as revascularization for all  patients with unstable angina or NSTEMI.'''
 ==Exclusion Criteria==
@@ Line 44: / Line 50: @@
 #VINO (2002) <ref>Spacek R, Widimsky P, Straka Z, et al. Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial. Eur Heart J. 2002;23: 230-238.</ref>
 #RITA (2002)<ref>Fox KA, Poole-Wilson PA, Henderson RA, et al; Randomized Intervention Trial of unstable Angina Investigators. Interventional versus conservative treat- ment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Lancet. 2002;360:743- 751.</ref>
 ==Outcomes via Meta-Analysis==
@@ Line 59: / Line 69: @@
 *41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)
 ==Review Questions==

Ostermayer: /* CME */

2014-04-03T14:47:23Z

CME

← Older revision		Revision as of 14:47, 3 April 2014
Line 60:		Line 60:
	*41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)		*41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)

	==~~CME~~==		==Review Questions==
	<quiz display=simple>		<quiz display=simple>
	{In the patient with an acute myocardial infarction and cardiogenic shock, which of the following constitutes optimal therapy?		{In the patient with an acute myocardial infarction and cardiogenic shock, which of the following constitutes optimal therapy?

Ostermayer at 11:47, 10 March 2014

2014-03-10T11:47:57Z

← Older revision		Revision as of 11:47, 10 March 2014
Line 13:		Line 13:
	\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087		\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087
	\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf		\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf
	\| status = ~~complete~~		\| status = Complete
	}}		}}
	==Clinical Question==		==Clinical Question==

Ostermayer at 01:50, 16 January 2014

2014-01-16T01:50:31Z

← Older revision	Revision as of 01:50, 16 January 2014
Line 1:	Line 1:
		{{JC info
		\| title= Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes
		\| abbreviation=
		\| expansion= Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes
		\| published= 2005
		\| author= Mehta, Shamir et al
		\| journal= JAMA
		\| year= 2005
		\| volume= 293
		\| issue= 23
		\| pages= 2908-2917
		\| pmid= 15956636
		\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087
		\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf
		\| status = complete
		}}
		==Clinical Question==
		Does percutaneous coronary intervention (PCI) for all patients with unstable angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) reduce death and recurrent myocardial infarction in comparison to only performing PCI in patient with recurrent or inducible ischemia?

		==Conclusion==
		Routine PCI reduced recurrent MI, severe angina, and rehospitalization over a mean follow-up of 17 months when compared to a more conservative selective strategy of PCI.

		==Major Points==
		*Higher-risk patients with elevated cardiac biomarker levels at baseline benefited more from routine intervention.
		*There was no significant benefit observed in lower-risk patients with negative cardiac markers.
		*During the initial hospitalization, a routine invasive strategy was associated with a significantly higher early mortality (1.1% vs 1.8%) vs the routine strategy.

		==Study Design==
		*A meta-analysis of studies from 1970 through June 2004
		*Trials were included if they enrolled patients with unstable angina or NSTEMI and randomly allocated patients to receive a routine invasive strategy or a se- lective invasive strategy
		*'''A selective invasive strategy (also referred to as a conservative or noninvasive strategy) was defined as an approach to patients who were initially treated with pharmacological therapy, after which cardiac catheterization and revascularization was performed only for those with recurrent symptoms.'''
		*'''A routine invasive strategy was defined as revascularization for all patients with unstable angina or NSTEMI.'''

		==Exclusion Criteria==
		*84 articles total were identified. 14 of the 84 were reports of the main findings of randomized controlled trials
		*7 were included in the meta-analysis and 7 were excluded because patient eligibility was based on results of coronary angiography and were limited to STEMI patients receiving thrombolytics

		''Studies Included in the meta-analysis:''
		#TIMI IIIB (1994) <ref>TIMI IIIB Investigators. Effects of tissue plasmino- gen activator and a comparison of early invasive and conservative strategies in unstable angina and non- Q-wave myocardial infarction: results of the TIMI IIIB trial. Circulation. 1994;89:1545-1556.</ref>
		#MATE (1998)<ref>McCullough PA, O’Neill WW, Graham M, et al. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. J Am Coll Cardiol. 1998;32:596-605.</ref>
		#VANQWISH (1998)<ref>Boden WE, O’Rourke RA, Crawford MH, et al; Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. Outcomes in patients with acute non-Q-wave myocar- dial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med. 1998;338:1785-1792.</ref>
		#FRISC II (1999)<ref>Fragmin and Fast Revascularisation during In- Stability in Coronary artery disease (FRISC II) Investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet. 1999;354:708-715</ref>
		#TACTICS-TIMI (2001)<ref>Cannon CP, Weintraub WS, Demopoulos LA, et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/ IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879- 1887.</ref>
		#VINO (2002) <ref>Spacek R, Widimsky P, Straka Z, et al. Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial. Eur Heart J. 2002;23: 230-238.</ref>
		#RITA (2002)<ref>Fox KA, Poole-Wilson PA, Henderson RA, et al; Randomized Intervention Trial of unstable Angina Investigators. Interventional versus conservative treat- ment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Lancet. 2002;360:743- 751.</ref>

		==Outcomes via Meta-Analysis==
		N=4608
		===In Hospital Hazards Outcomes===
		*'''Death:'''
		:82 (1.8%) in the routine invasive group died compared with 51 (1.1%) in the selective invasive group (OR, 1.60; 95% CI, 1.14-2.25; P = .007)
		*'''Myocardial Infarction:'''
		:171 (3.7%)had an MI during hospitalization in the routine invasive group, compared with 139 (3.0%) in the selective invasive group (OR, 1.24; 95% CI, 0.99- 1.56; P=.07)
		*'''Overall:'''
		:5.2% in the routine invasive group had a death or MI during the initial hospitalization compared with 3.8% in the selective invasive group (OR, 1.36; 95% CI, 1.12- 1.66; P=.002)

		===Outcomes after Hospital Discharge until Followup===
		*172 (3.8%) died compared with 223 (4.9%) of 4552 in the selective invasive group (OR, 0.76; 95% CI, 0.62- 0.94; P = .01)

		*41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)

		==CME==
		<quiz display=simple>
		{In the patient with an acute myocardial infarction and cardiogenic shock, which of the following constitutes optimal therapy?
		\|type="()"}

		-ensure adequate ventilation and oxygenation
		-treat emergent arrhythmias
		-administer aspirin if not aspirin allergic
		-arrange for emergent PCI
		+All of the above
		\|\|All of the above would be indicated, and consideration should be given for inotropic agents. Evidence from randomized trials suggests that emergent revascularization improves mortality rates at 6 months and one year.

		</quiz>

		==Sources==
		<references/>

		[[Category:EBQ]]

Ostermayer: Blanked the page

2014-01-16T01:50:20Z

Blanked the page

← Older revision		Revision as of 01:50, 16 January 2014
Line 1:		Line 1:
	~~{{JC info~~
	~~\| title= Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes~~
	~~\| abbreviation=~~
	~~\| expansion= Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes~~
	~~\| published= 2005~~
	~~\| author= Mehta, Shamir et al~~
	~~\| journal= JAMA~~
	~~\| year= 2005~~
	~~\| volume= 293~~
	~~\| issue= 23~~
	~~\| pages= 2908-2917~~
	~~\| pmid= 15956636~~
	~~\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087~~
	~~\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf~~
	~~\| status = complete~~
	}}
	~~==Clinical Question==~~
	Does percutaneous coronary intervention (PCI) for all patients with unstable angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) reduce death and recurrent myocardial infarction in comparison to only performing PCI in patient with recurrent or inducible ischemia?

	~~==Conclusion==~~
	~~Routine PCI reduced recurrent MI, severe angina, and rehospitalization over a mean follow-up of 17 months when compared to a more conservative selective strategy of PCI.~~

	~~==Major Points==~~
	*Higher-risk patients with elevated cardiac biomarker levels at baseline benefited more from routine intervention.
	*There was no significant benefit observed in lower-risk patients with negative cardiac markers.
	*During the initial hospitalization, a routine invasive strategy was associated with a significantly higher early mortality (1.1% vs 1.8%) vs the routine strategy.

	~~==Study Design==~~
	*A meta-analysis of studies from 1970 through June 2004
	*Trials were included if they enrolled patients with unstable angina or NSTEMI and randomly allocated patients to receive a routine invasive strategy or a se- lective invasive strategy
	*'''A selective invasive strategy (also referred to as a conservative or noninvasive strategy) was defined as an approach to patients who were initially treated with pharmacological therapy, after which cardiac catheterization and revascularization was performed only for those with recurrent symptoms.'''
	*'''A routine invasive strategy was defined as revascularization for all patients with unstable angina or NSTEMI.'''

	~~==Exclusion Criteria==~~
	*84 articles total were identified. 14 of the 84 were reports of the main findings of randomized controlled trials
	*7 were included in the meta-analysis and 7 were excluded because patient eligibility was based on results of coronary angiography and were limited to STEMI patients receiving thrombolytics

	~~''Studies Included in the meta-analysis:''~~
	#TIMI IIIB (1994) <ref>TIMI IIIB Investigators. Effects of tissue plasmino- gen activator and a comparison of early invasive and conservative strategies in unstable angina and non- Q-wave myocardial infarction: results of the TIMI IIIB trial. Circulation. 1994;89:1545-1556.</ref>
	#MATE (1998)<ref>McCullough PA, O’Neill WW, Graham M, et al. A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. J Am Coll Cardiol. 1998;32:596-605.</ref>
	#VANQWISH (1998)<ref>Boden WE, O’Rourke RA, Crawford MH, et al; Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. Outcomes in patients with acute non-Q-wave myocar- dial infarction randomly assigned to an invasive as compared with a conservative management strategy. N Engl J Med. 1998;338:1785-1792.</ref>
	#FRISC II (1999)<ref>Fragmin and Fast Revascularisation during In- Stability in Coronary artery disease (FRISC II) Investigators. Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. Lancet. 1999;354:708-715</ref>
	#TACTICS-TIMI (2001)<ref>Cannon CP, Weintraub WS, Demopoulos LA, et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators. Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/ IIIa inhibitor tirofiban. N Engl J Med. 2001;344:1879- 1887.</ref>
	#VINO (2002) <ref>Spacek R, Widimsky P, Straka Z, et al. Value of first day angiography/angioplasty in evolving non-ST segment elevation myocardial infarction: an open multicenter randomized trial. Eur Heart J. 2002;23: 230-238.</ref>
	#RITA (2002)<ref>Fox KA, Poole-Wilson PA, Henderson RA, et al; Randomized Intervention Trial of unstable Angina Investigators. Interventional versus conservative treat- ment for patients with unstable angina or non-ST-elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial. Lancet. 2002;360:743- 751.</ref>

	~~==Outcomes via Meta-Analysis==~~
	~~N=4608~~
	~~===In Hospital Hazards Outcomes===~~
	*'''Death:'''
	~~:82 (1.8%) in the routine invasive group died compared with 51 (1.1%) in the selective invasive group (OR, 1.60; 95% CI, 1.14-2.25; P = .007)~~
	*'''Myocardial Infarction:'''
	~~:171 (3.7%)had an MI during hospitalization in the routine invasive group, compared with 139 (3.0%) in the selective invasive group (OR, 1.24; 95% CI, 0.99- 1.56; P=.07)~~
	*'''Overall:'''
	~~:5.2% in the routine invasive group had a death or MI during the initial hospitalization compared with 3.8% in the selective invasive group (OR, 1.36; 95% CI, 1.12- 1.66; P=.002)~~

	~~===Outcomes after Hospital Discharge until Followup===~~
	*172 (3.8%) died compared with 223 (4.9%) of 4552 in the selective invasive group (OR, 0.76; 95% CI, 0.62- 0.94; P = .01)

	*41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)

	~~==CME==~~
	~~<quiz display=simple>~~
	~~{In the patient with an acute myocardial infarction and cardiogenic shock, which of the following constitutes optimal therapy?~~
	~~\|type="()"}~~

	~~-ensure adequate ventilation and oxygenation~~
	~~-treat emergent arrhythmias~~
	~~-administer aspirin if not aspirin allergic~~
	~~-arrange for emergent PCI~~
	~~+All of the above~~
	\|\|All of the above would be indicated, and consideration should be given for inotropic agents. Evidence from randomized trials suggests that emergent revascularization improves mortality rates at 6 months and one year.

	~~</quiz>~~

	~~==Sources==~~
	~~<references/>~~

	~~[[Category:EBQ]]~~

Ostermayer: clinical question

2014-01-15T16:06:08Z

clinical question

← Older revision		Revision as of 16:06, 15 January 2014
Line 16:		Line 16:
	}}		}}
	==Clinical Question==		==Clinical Question==
	Does percutaneous coronary intervention (PCI) for all patients with unstable angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) reduce death and recurrent myocardial infarction in comparison to only performing PCI in patient with recurrent or inducible ischemia		Does percutaneous coronary intervention (PCI) for all patients with unstable angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI) reduce death and recurrent myocardial infarction in comparison to only performing PCI in patient with recurrent or inducible ischemia?

	==Conclusion==		==Conclusion==

Ostermayer: Ostermayer moved page EBQ:Routine Invasive strategy in ACS to EBQ:Routine vs an Invasive strategy in ACS

2014-01-14T03:25:38Z

Ostermayer moved page EBQ:Routine Invasive strategy in ACS to EBQ:Routine vs an Invasive strategy in ACS

← Older revision	Revision as of 03:25, 14 January 2014
(No difference)

Ostermayer at 03:09, 14 January 2014

2014-01-14T03:09:26Z

← Older revision		Revision as of 03:09, 14 January 2014
Line 13:		Line 13:
	\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087		\| fulltexturl= http://jama.jamanetwork.com/article.aspx?articleid=201087
	\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf		\| pdfurl= http://jama.jamanetwork.com/data/Journals/JAMA/4980/JRV50012.pdf
			\| status = complete
	}}		}}
	==Clinical Question==		==Clinical Question==

Ostermayer: /* Outcomes via Meta-Analysis */

2014-01-14T03:08:58Z

Outcomes via Meta-Analysis

← Older revision		Revision as of 03:08, 14 January 2014
Line 57:		Line 57:
	*172 (3.8%) died compared with 223 (4.9%) of 4552 in the selective invasive group (OR, 0.76; 95% CI, 0.62- 0.94; P = .01)		*172 (3.8%) died compared with 223 (4.9%) of 4552 in the selective invasive group (OR, 0.76; 95% CI, 0.62- 0.94; P = .01)

			*41.3% in the invasive strategy were rehospitalized vs 32.5% in the selective strategy (OR, 0.66; 95% CI, 0.60-0.72; P=.001)

	==CME==		==CME==