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To the Editor: In their Review, Dr Mehta and colleagues¹ performed a meta-analysis that compared a routine invasive strategy with a selective invasive strategy in patients with unstable angina and non-ST-segment elevation (NSTE) acute coronary syndromes (ACS). The authors examined and pooled the results of 7 trials involving more than 9000 patients. They concluded that a routine invasive approach was associated with a nonsignificant reduction in overall mortality, although there was a significant increase in mortality during the index hospitalization.

Trials and registries that are included in a meta-analysis must be high quality, have reliable outcome data, and incorporate contemporary practices. A concern with this analysis is that it included several older trials (TIMI IIIB,² VANQWISH,³ and MATE⁴). These trials were performed before the era of glycoprotein (Gp) IIb/IIIa inhibitors and stents, which have been shown to improve adverse outcomes. The use of Gp IIb/IIIa inhibitors during percutaneous coronary . . . [Full Text of this Article]

Anthony A. Bavry, MD, MPH
bavrya@ccf.org
Department of Cardiovascular Medicine
Cleveland Clinic Foundation
Cleveland, Ohio

Dharam J. Kumbhani, MD, SM
Department of Internal Medicine
University of Pennsylvania
Philadelphia

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