This Article  • Full text  • PDF  • JAMA Report Video  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (9)  • Contact me when this article is cited  Related Content  • Similar articles in JAMA  Topic Collections  • Men's Health  • Men's Health, Other  • Cardiovascular System  • Quality of Care  • Evidence-Based Medicine  • Women's Health  • Women's Health, Other  • Review  • Prognosis/ Outcomes  • Cardiovascular Disease/ Myocardial Infarction  • Alert me on articles by topic  Social Bookmarking   What's this?

A Meta-analysis

Michelle O’Donoghue, MD; William E. Boden, MD; Eugene Braunwald, MD; Christopher P. Cannon, MD; Tim C. Clayton, MSc; Robbert J. de Winter, MD, PhD; Keith A. A. Fox, MB, ChB; Bo Lagerqvist, MD, PhD; Peter A. McCullough, MD, MPH; Sabina A. Murphy, MPH; Rudolf Spacek, MD, PhD; Eva Swahn, MD, PhD; Lars Wallentin, MD, PhD; Fons Windhausen, MD; Marc S. Sabatine, MD, MPH

JAMA. 2008;300(1):71-80.

Context  Although an invasive strategy is frequently used in patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS), data from some trials suggest that this strategy may not benefit women.

Objective  To conduct a meta-analysis of randomized trials to compare the effects of an invasive vs conservative strategy in women and men with NSTE ACS.

Data Sources  Trials were identified through a computerized literature search of the MEDLINE and Cochrane databases (1970-April 2008) using the search terms invasive strategy, conservative strategy, selective invasive strategy, acute coronary syndromes, non-ST-elevation myocardial infarction, and unstable angina.

Study Selection  Randomized clinical trials comparing an invasive vs conservative treatment strategy in patients with NSTE ACS.

Data Extraction  The principal investigators for each trial provided the sex-specific incidences of death, myocardial infarction (MI), and rehospitalization with ACS through 12 months of follow-up.

Data Synthesis  Data were combined across 8 trials (3075 women and 7075 men). The odds ratio (OR) for the composite of death, MI, or ACS for invasive vs conservative strategy in women was 0.81 (95% confidence interval [CI], 0.65-1.01; 21.1% vs 25.0%) and in men was 0.73 (95% CI, 0.55-0.98; 21.2% vs 26.3%) without significant heterogeneity between sexes (P for interaction = .26). Among biomarker-positive women, an invasive strategy was associated with a 33% lower odds of death, MI, or ACS (OR, 0.67; 95% CI, 0.50-0.88) and a nonsignificant 23% lower odds of death or MI (OR, 0.77; 95% CI, 0.47-1.25). In contrast, an invasive strategy was not associated with a significant reduction in the triple composite end point in biomarker-negative women (OR, 0.94; 95% CI, 0.61-1.44; P for interaction = .36) and was associated with a nonsignificant 35% higher odds of death or MI (OR, 1.35; 95% CI, 0.78-2.35; P for interaction = .08). Among men, the OR for death, MI, or ACS was 0.56 (95% CI, 0.46-0.67) if biomarker-positive and 0.72 (95% CI, 0.51-1.01) if biomarker-negative (P for interaction = .09).

Conclusions  In NSTE ACS, an invasive strategy has a comparable benefit in men and high-risk women for reducing the composite end point of death, MI, or rehospitalization with ACS. In contrast, our data provide evidence supporting the new guideline recommendation for a conservative strategy in low-risk women.

Author Affiliations: TIMI Study Group, Brigham and Women's Hospital (Drs O’Donoghue, Braunwald, Cannon, and Sabatine, and Ms Murphy) and Massachusetts General Hospital (Dr O’Donoghue), Boston, Massachusetts; Buffalo General Hospital, Buffalo, New York (Dr Boden); London School of Hygiene and Tropical Medicine, London, England (Mr Clayton); Academic Medical Center, Amsterdam, the Netherlands (Drs de Winter and Windhausen); University and Royal Infirmary of Edinburgh, Edinburgh, Scotland (Dr Fox); Uppsala University Hospital, Uppsala, Sweden (Drs Lagerqvist and Wallentin); William Beaumont Hospital, Royal Oak, Michigan (Dr McCullough); Hospital Na Frantisku, Prague, Czech Republic (Dr Spacek); and University Hospital, Linkoping, Sweden (Dr Swahn).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Women and ischemic heart disease: evolving knowledge.
Shaw et al.
J Am Coll Cardiol 2009;54:1561-1575.
ABSTRACT | FULL TEXT  

Acute Coronary Syndromes: Diagnosis and Management, Part I
Kumar and Cannon
Mayo Clin Proc. 2009;84:917-938.
ABSTRACT | FULL TEXT  

Determinants and outcomes of coronary angiography after non-ST-segment elevation myocardial infarction. A cohort study of the Myocardial Ischaemia National Audit Project (MINAP)
Birkhead et al.
Heart 2009;95:1593-1599.
ABSTRACT | FULL TEXT  

Long-Term Mortality of Patients Undergoing Cardiac Catheterization for ST-Elevation and Non-ST-Elevation Myocardial Infarction
Chan et al.
Circulation 2009;119:3110-3117.
ABSTRACT | FULL TEXT  

COURAGE to change practice? Revascularisation in patients with stable coronary artery disease
Fox
Heart 2009;95:689-692.
FULL TEXT  

Early invasive compared with a selective invasive strategy in women with non-ST-elevation acute coronary syndromes: a substudy of the OASIS 5 trial and a meta-analysis of previous randomized trials
Swahn et al.
Eur Heart J 2009;0:ehp009v1-10.
ABSTRACT | FULL TEXT  

Coronary Intervention in 2009: Are Women No Different Than Men?
Jacobs
Circ Cardiovasc Interv 2009;2:69-78.
FULL TEXT  

When Should a New Test Become the Current Reference Standard?
Glasziou et al.
ANN INTERN MED 2008;149:816-821.
ABSTRACT | FULL TEXT  

The Year in Non-ST-Segment Elevation Acute Coronary Syndrome
Giugliano and Braunwald
J Am Coll Cardiol 2008;52:1095-1103.
FULL TEXT  

BMJ 2008;337:a694-a694.
FULL TEXT