European Heart Journal Advance Access published online on February 7, 2009
European Heart Journal, doi:10.1093/eurheartj/ehp009
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
1 Division of Cardiology, Department of Medical and Health Sciences, Linköping Heart Centre, University Hospital, SE 581 85 Linköping, Sweden
2 Department of Medicine, McMaster University, Hamilton, Canada
3 Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
4 Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
5 Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
Received 7 July 2008; revised 22 December 2008; accepted 5 January 2009.
* Corresponding author. Tel: +46 13 222000, Fax: +46 13 222171, Email: eva.swahn{at}lio.se
Aims: The aim of this study was to compare benefits and risks of a routine invasive compared with a selective invasive strategy in women with non-ST-elevation acute coronary syndromes.
Methods and results: We randomly assigned 184 women, either to a routine or to a selective invasive strategy as a substudy to the OASIS 5 trial, who were followed for 2 years. Meta-analysis of data from previous randomized trials was also done. There were no significant differences between the two treatment strategies in the primary outcome death/myocardial infarction (MI)/stroke [21.0 vs. 15.4%, HR = 1.46, 95% CI (0.73–2.94)], in the secondary outcome death/MI [18.8 vs. 14.3%, HR = 1.39, 95% CI (0.67–2.88)], or separately analysed outcomes MI [12.9 vs. 13.3%, HR = 0.95, 95% CI (0.42–2.19)] or stroke [2.3 vs. 4.4%, HR = 0.67, 95% CI (0.12–3.70)]. However, there were significantly more deaths after 1 year (8.8 vs. 1.1%, HR = 9.01, 95% CI (1.11–72.90) and a higher rate of major bleeding at 30 days [8.8 vs. 1.1%, HR = 11.45, 95% CI (1.43–91.96)] in the routine invasive strategy group. A meta-analysis including 2692 women in previous randomized trials, with a gender perspective, showed no significant difference in the composite outcome death/MI, OR = 1.18, 95% CI (0.92–1.53) but a higher mortality with a routine invasive strategy for women, OR = 1.51, 95% CI (1.00–2.29).
Conclusion: The rate of death, MI, or stroke in women was not different in patients treated with a routine invasive strategy compared with a selective invasive strategy, but there was a concerning trend towards higher mortality. When combined with data from previous trials, there does not appear to be a benefit of an early invasive strategy in women with ACS, which differs from the results in men. These data emphasize the lack of clear evidence in favour of an invasive strategy in women and suggest caution in extrapolating the results from men to women.
Key Words: Women • Non-ST-elevation acute coronary syndrome • Invasive strategy