EBQ:Routine vs an Invasive strategy in ACS

Complete Journal Club Article
Mehta, Shamir et al. "Routine vs Selective Invasive Strategies in Patients With Acute Coronary Syndromes". JAMA. 2005. 293(23):2908-2917.
PubMed Full text PDF

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?


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:

  1. TIMI IIIB (1994) [1]
  2. MATE (1998)[2]
  3. VANQWISH (1998)[3]
  4. FRISC II (1999)[4]
  5. TACTICS-TIMI (2001)[5]
  6. VINO (2002) [6]
  7. RITA (2002)[7]

Outcomes via Meta-Analysis


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)

Review Questions

In the patient with an acute myocardial infarction and cardiogenic shock, which of the following constitutes optimal therapy?

ensure adequate ventilation and oxygenation
treat emergent arrhythmias
administer aspirin if not aspirin allergic
arrange for emergent PCI
All of the above


  1. 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.
  2. 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.
  3. 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.
  4. 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
  5. 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.
  6. 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.
  7. 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.