Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome (original) (raw)
Related papers
Journal of the American Heart Association, 2021
Background The optimal timing of invasive examination and treatment of high‐risk patients with non–ST‐segment–elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard‐care invasive coronary angiography on the risk of all‐cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. Methods and Results Patients with clinical suspicion of non–ST‐segment–elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48–72 hours) invasive strategy. The primary outcome of the present study w...
European Heart Journal Supplements, 2021
The European Society of Cardiology guidelines on non-ST-elevation acute coronary syndromes suggest different temporal strategies for the angiographic study depending on the risk profile. The scientific evidence underlying the guideline recommendations and the critical issues currently existing in Italy, that often do not allow either an extended strategy of revascularization within 24 h or the application of the principle of the same day transfer from a spoke to a hub centre, are analysed. The position paper focuses, in particular, on the subgroup of patients with a defined diagnosis of non-ST-elevation myocardial infarction by proposing a timing of coronary angiography/revascularization that takes into account the available scientific evidence and the organizational possibilities of a considerable part of national cardiology services.
Journal of the American College of Cardiology, 2017
The ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years. The aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T. The ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or ...
Early invasive strategy in non-ST-segment elevation acute coronary syndrome. The paradox continues
2012
Objective: Observational studies have reported a paradoxical inverse relationship between the use of an early invasive strategy (EIS) and the risk of events in patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). The study objectives are: (1) to examine the association between baseline risk in patients with NSTE ACS and the use of EIS; and (2) to identify some of the factors independently associated to the use of EIS. Design: Retrospective cohort study. Setting: Intensive care units participating in the SEMICYUC ARIAM Registry. Patients: Consecutive patients admitted with a diagnosis of NSTE-ACS within 48 h of evolution between the months of April and July 2010. Interventions: None. Main outcomes: Coronary angiography with or without angioplasty within 72 h, risk stratification using the GRACE scale. Results: We analyzed 543 patients with NSTE-ACS, of which 194 were of low risk, 170 intermediate risk and 179 high risk. The EIS was used in 62.4% of the patients at low risk, in 60.2% of those with intermediate risk, and in 49.7% of those at high risk (p for tendency 0.0144). The EIS was used preferentially in patients with low severity and comorbidity. In the logistic regression model, EIS was independently associated to the availability of a catheterization laboratory (OR 2.22 [95%CI 1.55-3.19]), the presence of ST changes on ECG (OR 1.80 [1.23-2.64]), or the existence of a low risk of bleeding (OR 0.76 [0.66-0.88)]. Conversely, EIS was less prevalent in patients with diabetes (OR 0.60 [0.41-0.88]) or tachycardia upon admission (OR 0.54 [0 36-0.82]). ଝ Please cite this article as: Latour-Pérez J, et al. Uso de la estrategia invasiva precoz en el síndrome coronario agudo sin elevación de ST.
Two-year outcome after early or late Intervention in non-ST elevation acute coronary syndrome
Open heart, 2017
To compare long-term outcome of an early to a delayed invasive strategy in high-risk patients with non-ST elevation acute coronary syndrome (NSTE-ACS). This prospective, multicentre trial included patients with NSTE-ACS and at least two out of three of the following high-risk criteria: (1) evidence of extensive myocardial ischaemia on ECG, (2) elevated biomarkers for myocardial necrosis and (3) age above 65 years. Patients were randomised to either an early (angiography and revascularisation if appropriate <12 hours) or a delayed invasive strategy (>48 hours after randomisation). Endpoint for this prespecified long-term follow-up was the composite incidence of death or reinfarction after 2 years. Data collection was performed by telephone contact with the patients, their relatives or general practitioner and by review of hospital records. Endpoint status after 2-year follow-up was collected in 521 of 542 initially enrolled patients. Incidence of death or reinfarction was 11.8%...
Critical pathways in cardiology, 2015
Management of acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) and unstable angina pectoris (UAP) remains challenging. The study aimed to analyze the current management of UAP patients in German chest pain units focussing on the different time lines of invasive strategy. A total of 1400 UAP patients admitted to a certified chest pain unit were enrolled. Analyses of high-risk criteria with indication for invasive management and of 3-month clinical outcomes were performed by subgrouping UAP patients to immediate and early invasive (<8 hours), early elective invasive (8-24 hours), late elective invasive (24-72 hours) strategy, and without percutaneous coronary intervention (PCI). Coronary angiography was performed in 60.6% of the UAP patients, whereas PCI was necessary in 37%. Only 1.4% of the UAP patients obtained immediate PCI within the first 120 minutes. In 16.9%, patients received PCI within the first day of hospitalization or even within the first 8 ...
Scientific Reports
Coronary angiography (CA) is the basis of an invasive management strategy in non-ST elevation acute coronary syndromes (NSTEACS). There are limited contemporary data on national temporal trends in utilization of CA in different patient subgroups. We sought to investigate temporal trends, predictors and clinical outcomes associated with the use of CA in the US. Using the Nationwide Inpatient Sample (NIS) from 2004-2014, we identified all inpatient admissions, age ≥18, with a primary diagnosis of NSTEACS. Descriptive statistics and multivariable logistic regression models were used to investigate temporal trends, predictors and clinical outcomes associated with CA. From a total of 4,380,827 patients, 57.5% received CA during the study period and were more likely to be male, younger and less comorbid as defined per Charlson comorbidity index. The proportion of patients receiving CA increased from 48.5% to 68.5%, however, higher proportional increase was observed in males (53.9% to 69.4% P trend < 0.001) and those age ≤60 years (59.0% to 77.9% P trend < 0.001). Prior history of CABG (OR 0.33 95%CI 0.35-0.36), previous PCI (OR 0.84 95%CI 0.83-0.86) and previous AMI (OR 0.65 95%CI 0.64-0.67) were inversely related with receipt of CA. Receipt of CA was strongly associated with decreased odds of in-hospital mortality (OR 0.38 95%CI 0.36-0.40). In this national analysis, we observed a temporal increase in utilization of CA albeit slower adoption was noted in older, women and more comorbid patients. The risk-treatment paradox wherein patients who are most likely to benefit were less likely to receive CA persists even in contemporary practice. Non-ST-Elevation acute coronary syndromes (NSTEACS) are estimated to account for almost two-thirds of total hospital admissions for an acute coronary syndrome in the United States and Europe 1-4. Despite the use of pharmacoinvasive strategies, NSTEACS remains the most vulnerable acute coronary syndrome phenotype with high mortality and morbidity 5-8. Guidelines from national bodies emphasize the use of coronary angiography (CA) in patients presenting with NSTEACS particularly in unstable or high-risk patients 9,10 with data from observational and randomized control trials demonstrating improved outcomes in patients receiving early invasive CA 11,12. Despite the established benefit of an early invasive strategy in patients with NSTEACS, significant variations in the utilization of CA both at regional and national levels remain. The decision to undertake an invasive approach