Eight RCTs were included (n=1,318 reported in text and n=1,177 according to tables). Five RCTs (n=623) compared RT versus conservative treatment, two RCTs (n=127) compared rescue PCI versus conservative treatment and one RCT (n=427) compared RT versus PCI versus conservative treatment.
Overall, trials were judged to be at low risk of bias according to the Cochrane Collaboration criteria. The average Jadad score was 3.2 (2.8 for rescue PCI studies and 4.0 for RT studies). There was no evidence of publication bias.
RT versus conservative treatment: There was no significant difference between RT and conservative treatment for major adverse events, overall mortality, re-infarction or major bleeds. RT was associated with a statistically significant increase in minor bleeds in fixed-effect but not random-effects models (OR fixed-effect 2.08, 95% CI: 1.09, 3.98, p=0.03, I2 55.5%, NNH 14).
Rescue PCI versus conservative treatment: Using fixed effect models, rescue PCI compared to conservative treatment was associated with a statistically significant reduction in the risk of major adverse events (OR 0.59, 95% CI: 0.41, 0.86, p=0.006, I2 33%, NNH 14) and re-infarction (OR 0.55, 95% CI: 0.31, 0.96, p=0.04, I2 22%, NNH 25) but a statistically significant increase in stroke (OR 5.11, 95% CI: 1.11, 23.49, p=0.04, I2 0%, NNH 33). OR from random-effects models were significant for major adverse events and stroke but not for re-infarction. There was a statistically significant increase in minor bleeds for rescue PCI compared to conservative treatment groups (OR 5.47, 95% CI: 2.78, 10.76, p<0.001, I2 0%, NNH 9). Only one trial assessed major bleeds.
Moderate inconsistency was found for most comparisons.
Adjusted indirect comparison of RT versus rescue PCI: There were no significant differences between RT and rescue PCI for major adverse events, overall mortality or congestive cardiac failure. Rescue PCI was associated with a statistically significant reduction in the risk of re-infarction (OR 0.32, 95% CI: 0.14, 0.74; p=0.008, NNT 17). There was no significant difference between treatment groups in the risk of major bleeds but there was a statistically significant increase in minor bleeds with rescue PCI (OR 2.48, 95% CI: 1.08, 5.7, p=0.04, NNH 50).