Original title: Impact of an invasive strategy on five years outcomein men and women with Non-ST-Elevation Acute Coronary Syndromes. Reference: Joakim Alfredsson et al. Am Heart J. 2014;Epub ahead of print.

This meta-analysis included patients with non-ST-elevation acute coronary syndrome (NSTE ACS) from randomized studies FRISC II, ICTUS and RITA 3 and compared the routine invasive strategy (n=2721) with coronary catheterization and, when possible, angioplasty or surgery vs. a more selective strategy (n=2746) consisting of initial stabilization with medical therapy, leaving coronary catheterization for patients with recurrent ischemia symptoms despite medical treatment, hemodynamically unstable, or showing signs of ischemia on a stress test. 

Women represented one third of overall cohort (n=1751), were of older age, smoked less and had higher hypertension rates than men. On the other hand, men often had a history of MI and revascularization.

After a 5 year follow up, routine invasive strategy in men reduced primary end point of cardiovascular death or AMI (15.6% vs 19.8%; p=0.01), and individual components, cardiovascular death (6.6% vs 8,7%; p=0.07) and AMI (10.8% vs 14.6%; p=0.01). These same points saw no significant change in women.

In the light of a risk stratified analysis, men presenting medium or high risk non ST elevation AMI at baseline, saw benefit from the routine invasive strategy. On the contrary, women in all risk subgroups saw a similar prognosis, regardless of treatment strategy. 

Conclusion

This meta-analysis based in three large randomized studies on non ST elevation AMI confirmed the long term benefit of routine invasive strategy in men, while women saw no significant benefit.

Editorial Comment

Subgroup analysis, especially if not pre specified by protocol, must be interpreted with caution. Even in this large dataset, the number of events in women was low and the difference between men and women could be the result of weak statistical power in women.

Among randomized patients undergoing routine invasive strategy, women often lack significant lesions (28.2% vs 9.3%) and are less likely to have 3 vessel lesions (21.1% vs 30.6%). 

To conclude, women had less severe coronary disease and this may have reduced the benefit of a routine invasive strategy. Today, guidelines have no specific recommendation as regards gender for non ST elevation AMI syndromes. 

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