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Background Very few studies have evaluated the potential of using B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) as surrogate markers to guide clinical interventional or conservative therapy decisions. Aim The aim of the current study was to evaluate the potential of using BNP and NT-proBNP as surrogate markers to guide clinical interventional or conservative therapy decisions. Methods We identified randomized controlled trials that randomized patients with acute coronary syndrome (ACs) of unstable angina and myocardial infarction without sT-segment elevation ACs to early invasive therapy versus a more conservative approach by systematic search of articles and databases. Results Five randomized controlled trials with a total of 8125 patients and with a mean duration of 11.2months were included in the meta-analysis. At a mean follow-up of 11.2months, the incidence of all-cause mortality was 5.9% in the early invasive group, compared with 6.8% in the conservative group (risk ratio=0.74; 95% confidence interval, 0.59-0.86; P = 0.001). Conclusions in summary, BNP/NT-proBNP-guided management of ACs is significantly improved by early invasive therapy by improving long-term survival and reducing nonfatal myocardial infarction for unstable angina. However, there does not seem to be a clear benefit of using such a strategy over existing clinical recommendations.