Revascularization vs. Optimal Medical Therapy in Women with NSTE-ACS

Background: There is conflicting evidence regarding the benefit of an early invasive strategy vs. a conservative strategy in women with non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods: We searched English-language studies on MEDLINE and the Cochrane Database of Systematic Reviews from 2000 to December 2015. Results from major available studies and meta-analysis comparing outcomes of an early invasive strategy vs. a conservative strategy or medical therapy vs. revascularization in women with NSTE-ACS were considered. Results: Available data on the comparative effectiveness and safety of different management strategies in NSTE-ACS women derive from observational registries and pre-specified gender sub-analyses of randomized trials comparing early routine invasive with a selective invasive strategy. While some post-hoc analysis of randomized trials showed that an early invasive strategy did not reduce the risk of future events among women, in contrast to its beneficial effect in men, others showed similar benefits of a routine early invasive vs. a conservative strategy in men and women. Several important differences between these trials may explain the lack of benefits from a routine invasive strategy compared with a conservative strategy. Overall evidence showed better outcomes with a routine invasive strategy, especially for women at higher risk and those with positive biomarkers. Differently, women with negative biomarkers and those at lower risk appeared to benefit most from a conservative approach. Conclusion: The benefit of an early invasive strategy is restricted to women at higher risk. Further research is warranted to define the optimal management of women with NSTE-ACS.