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Invasive Versus Conservative Treatment Strategy in Older Patients With Non-ST Segment Elevation Acute Coronary Syndromes: A Meta-Analysis of Randomized Controlled Trials

Author/s: 
Mushood Ahmed, Areeba Ahsan, Aimen Shafiq, Tallal Mushtaq Hashmi

Background
Non-ST segment elevation acute coronary syndromes (NSTE-ACS) are a common cause of hospital admission in older patients. Our study aims to synthesize the available evidence from randomized controlled trials (RCTs) to compare clinical outcomes with invasive versus conservative medical management in this population.

Methods
A literature search of online databases including PubMed/MEDLINE, Embase, and the Cochrane Library was conducted from inception to September 1, 2024. The search aimed to identify RCTs that reported clinical outcomes with invasive versus conservative strategies in older patients (≥ 70 years) with NSTE-ACS. The risk ratios (RRs) were used as summary estimates.

Results
Seven RCTs with 2998 patients were included; 1490 patients in the invasive group and 1508 patients in the conservatively managed group. The pooled analysis demonstrated no statistically significant difference between the two strategies for the risk of all-cause death (RR: 1.03, 95% CI: 0.92–1.15), cardiovascular death (RR: 1.04, 95% CI: 0.82–1.33), stroke (RR: 0.78, 95% CI: 0.53–1.15), and major bleeding (RR: 1.23, 95% CI: 0.90–1.69). However, the invasive strategy was associated with a significantly reduced risk of myocardial infarction (RR: 0.74, 95% CI: 0.57–0.96) and unplanned revascularization (RR: 0.29, 95% CI: 0.21–0.40) compared to the conservative strategy.

Conclusion
In older patients with NSTE-ACS, an invasive strategy reduces the risk of repeat myocardial infarction and unplanned revascularization without a significant increase in stroke or major bleeding. There was no associated reduction in all-cause or cardiovascular mortality with the invasive strategy compared to conservative management.

Keywords 
NSTEMI Conservative treatment invasive treatment revascularization unstable angina pectoris

Conservative versus surgical management for patients with rotator cuff tears: a systematic review and META-analysis

Author/s: 
Longo, Umile G., Ambrogioni, Laura R., Candela, Vincenzo, Berton, Alessandra, Carnevale, Arianna, Schena, Emiliano, Denaro, Vincenzo

Background: This study aims to compare conservative versus surgical management for patients with full-thickness RC tear in terms of clinical and structural outcomes at 1 and 2 years of follow-up.

Methods: A comprehensive search of CENTRAL, MEDLINE, EMBASE, CINAHL, Google Scholar and reference lists of retrieved articles was performed since the inception of each database until August 2020. According to the Cochrane Handbook for Systematic Reviews of Interventions, two independent authors screened all suitable studies for the inclusion, extracted data and assessed risk of bias. Only randomised controlled trials comparing conservative and surgical management of full-thickness RC tear in adults were included. The primary outcome measure was the effectiveness of each treatment in terms of Constant-Murley score (CMS) and VAS pain score at different time points. The secondary outcome was the integrity of the repaired tendon evaluated on postoperative MRI at different time points. The GRADE guidelines were used to assess the critical appraisal status and quality of evidence.

Results: A total of six articles met the inclusion criteria. The average value of CMS score at 12 months of follow-up was 77.6 ± 14.4 in the surgery group and 72.8 ± 16.5 in the conservative group, without statistically significant differences between the groups. Similar results were demonstrated at 24 months of follow-up. The mean of VAS pain score at 12 months of follow-up was 1.4 ± 1.6 in the surgery group and 2.4 ± 1.9 in the conservative group. Quantitative synthesis showed better results in favour of the surgical group in terms of VAS pain score one year after surgery (- 1.08, 95% CI - 1.58 to - 0.58; P < 0.001).

Conclusions: At a 2-year follow-up, shoulder function evaluated in terms of CMS was not significantly improved. Further high-quality level-I randomised controlled trials at longer term follow-up are needed to evaluate whether surgical and conservative treatment provide comparable long-term results.

Keywords 
Conservative treatment 2019-nCOV Physiotherapy Rotator cuff Rotator cuff repair Rotator cuff tear Shoulder surgery Surgical treatment
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