The protective role of phosphodiesterase inhibitors in preventing colorectal cancer and advanced colorectal polyps: a systematic review and meta-analysis.

AIM: Inflammatory cells within the tumour microenvironment are the driving forces behind colorectal cancer (CRC) tumourigenesis. Understanding the different pathways involved in CRC carcinogenesis paves the way for effective repurposing of drugs for cancer prevention. Emerging data from preclinical and clinical studies suggest that, due to their antiproliferative and anti-inflammatory properties, phosphodiesterase-5 inhibitors (PDE5i) might have an anticancer effect. The aim of this study was to clarify through systematic review and meta-analysis of published peer-reviewed studies whether an association exists between PDE5i use and CRC risk. METHOD: This study was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Prospective registration was performed on PROSPERO (CRD42022372925). A systematic review was performed for studies reporting CRC and advanced colorectal polyp incidence in PDE5i 'ever-users' and PDE5i 'never-users'. Meta-analysis was performed using RevMan version 5. RESULTS: Four observational cohort studies and two case-control studies, comprising 995 242 patients were included in the final analysis, of whom 347 126 were PDE5i ever-users. Patients who were PDE5i ever-users had a significantly lower incidence of CRC or advanced colorectal polyps than never-users (OR 0.88, CI 0.79-0.98, p = 0.02). To examine the primary preventative role of PDE5i, subgroup analysis of four studies including patients without a previous history of CRC found that use of PDE5i was associated with a lower incidence of CRC (OR 0.85, CI 0.75-0.95, p = 0.005, I2 = 64%). There was no significant temporal relationship found between PDE5i use and CRC risk as both current users and previous users had a significantly lower incidence of CRC than never-users. CONCLUSION: Our study found a significant anticancer effect of PDE5i, as shown by a reduced risk of CRC in the context of both primary and secondary CRC prevention.

Fundamental drivers for endolithic microbial community assemblies in the hyperarid Atacama Desert.

In hyperarid deserts, endolithic microbial communities colonize the rocks' interior as a survival strategy. Yet, the composition of these communities and the drivers promoting their assembly are still poorly understood. We analysed the diversity and community composition of endoliths from four different lithic substrates - calcite, gypsum, ignimbrite and granite - collected in the hyperarid zone of the Atacama Desert, Chile. By combining microscopy, mineralogy, spectroscopy and high throughput sequencing, we found these communities to be highly specific to their lithic substrate, although they were all dominated by the same four main phyla, Cyanobacteria, Actinobacteria, Chloroflexi and Proteobacteria. Our finding indicates a fine scale diversification of the microbial reservoir driven by substrate properties. The data suggest that the overall rock chemistry and the light transmission properties of the substrates are not essential drivers of community structure and composition. Instead, we propose that the architecture of the rock, i.e., the space available for colonization and its physical structure, linked to water retention capabilities, is ultimately the driver of community diversity and composition at the dry limit of life.

Missed myocardial infarctions in ED patients prospectively categorized as low risk by established risk scores.

STUDY OBJECTIVES: Few studies have prospectively compared multiple cardiac risk prediction scores. We compared the rate of missed acute myocardial infarction (AMI) in chest pain patients prospectively categorized as low risk by unstructured clinical impression, and by HEART, TIMI, GRACE, and EDACS scores, in combination with two negative contemporary cardiac troponins (cTn) available in the U.S. METHODS: We enrolled 434 patients with chest pain presenting to one of seven emergency departments (ED). Risk scores were prospectively calculated and included the first two cTn. Low risk was defined for each score as HEART≤3, TIMI≤0, GRACE≤50, and EDACS≤15. AMI incidence was calculated for low risk patients and compared across scores using Χ2 tests and C statistics. RESULTS: The patients' median age was 57, 58% were male, 60% white, and 80 (18%) had AMI. The missed AMI rate in low risk patients for each of the scores when combined with 2 cTn were HEART 3.6%, TIMI 0%, GRACE 6.3%, EDACS 0.9%, and unstructured clinical impression 0%. The C-statistic was greatest for the EDACS score, 0.94 (95% CI, 0.92-0.97). CONCLUSIONS: Using their recommended cutpoints and non high sensitivity cTn, TIMI and unstructured clinical impression were the only scores with no missed cases of AMI. Using lower cutpoints (GRACE≤48, TIMI=0, EDACS≤11, HEART≤2) missed no case of AMI, but classified less patients as low-risk.

Impact of the United kingdom national bowel cancer awareness campaign on colorectal services.

BACKGROUND: Poor public awareness may account for the advanced stage at diagnosis, hence, poorer survival. With the aim of reducing colorectal cancer deaths, the United Kingdom National Bowel Cancer Awareness Campaign was rolled out from January 2012. Currently, the United Kingdom government target is to have all patients suspected to have cancer seen within 2 weeks of referral from general practitioners. This has significant impact on the workload for endoscopists. OBJECTIVE: The study aimed to measure the impact on colorectal services following the National Bowel Cancer Awareness Campaign. DESIGN: The data between February and July 2012 (onset of campaign) were prospectively collected and compared with data retrospectively collected between February and July 2011 inclusive (before campaign). SETTINGS: This study was conducted at a single center, university hospital. PATIENTS: The number of 2-week wait referrals, investigations, and colorectal cancers detected were assessed. MAIN OUTCOME MEASURES: Demographics, staging, and treatment of cancers were compared between groups along with the uptake of colorectal cancer screening. RESULTS: The total number of 2-week wait referrals increased by 47% with a resultant 38% increase in colonic investigations (p = 0.034) and a 23% increase in cancers detected (p = 0.0157). There was a 6.5% increase in the uptake of screening (p = 0.001) and a 62.5% decrease in the number of patients with colorectal cancer presenting as an emergency. LIMITATIONS: This short period of study is a major limitation. Although the data were from prospectively maintained databases, some data were analyzed retrospectively. Because only a single unit was assessed, results across a wider population may be more pronounced. There was also a referral bias in the compliance of primary care in the adherence to the 2-week wait referral criteria, because these criteria can be abused to get anxious patients into secondary care quickly. CONCLUSIONS: The National Bowel Cancer Awareness Campaign significantly increased the demand for colorectal services. With a potentially more favorable oncological outcome, further evaluation of supporting this greater workload demand is warranted.

Increased central adiposity in morbidly obese patients with obstructive sleep apnoea.

BACKGROUND: With the growing epidemic of obesity, few data are available regarding adipose distribution and the severity of sleep apnoea. Our aim was to measure precisely adipose distribution with dual-energy X-ray absorptiometry (DXA) in a morbidly obese population with and without obstructive sleep apnoea (OSA). METHODS: Morbidly obese female subjects without a history of OSA underwent overnight polysomnography and DXA analysis. Subject demographics, DXA variables, serum laboratory markers and physical exam characteristics were compared between individuals with and without OSA. RESULTS: For the study population (n= 26), mean body mass index (BMI) was 45.9 ± 7.8 kg/m(2); mean age was 47.5 ± 10.2 years and all were female. The central adiposity ratio (CAR) was higher in individuals with OSA (apnoea-hypopnoea index > 5) than those without OSA (1.1 ± 0.05 vs 1.0 ± 0.04; P = 0.004). No difference was observed in Epworth Sleepiness Scale scores, body mass index (BMI) or neck circumference between groups. CONCLUSIONS: OSA is associated with increased central adipose deposition in patients with a BMI of >40 kg/m(2). These data may be helpful in designing future studies regarding the pathophysiology of OSA, and potential treatment options.

Ivermectin: a multifaceted drug of Nobel prize-honoured distinction with indicated efficacy against a new global scourge, COVID-19.

In 2015, the Nobel Committee for Physiology or Medicine, in its only award for treatments of infectious diseases since six decades prior, honoured the discovery of ivermectin (IVM), a multifaceted drug deployed against some of the world's most devastating tropical diseases. Since March 2020, when IVM was first used against a new global scourge, COVID-19, more than 20 randomized clinical trials (RCTs) have tracked such inpatient and outpatient treatments. Six of seven meta-analyses of IVM treatment RCTs reporting in 2021 found notable reductions in COVID-19 fatalities, with a mean 31% relative risk of mortality vs. controls. During mass IVM treatments in Peru, excess deaths fell by a mean of 74% over 30 days in its ten states with the most extensive treatments. Reductions in deaths correlated with the extent of IVM distributions in all 25 states with p < 0.002. Sharp reductions in morbidity using IVM were also observed in two animal models, of SARS-CoV-2 and a related betacoronavirus. The indicated biological mechanism of IVM, competitive binding with SARS-CoV-2 spike protein, is likely non-epitope specific, possibly yielding full efficacy against emerging viral mutant strains.

ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference.

Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.

Cardiovascular risk modification in participants with coronary disease screened by the Kidney Early Evaluation Program.

BACKGROUND: Coronary artery disease (CAD) identifies the need for intensive treatment of risk factors among individuals with chronic kidney disease (CKD), a high-risk, complex cardiovascular risk state. METHODS: An estimated glomerular filtration rate<60 mL/min/1.73 m2 or a urine albumin:creatinine ratio (ACR)≥30 mg/g (3.4 mg/mmol) defined CKD. RESULTS: Of 70,454 volunteers screened the mean age was 53.5±15.7 years and 68.3% were female. A total of 5410 (7.7%) had a self-reported history of CAD; 1295 (1.8%) had a history of prior percutaneous coronary intervention (PCI); and 1124 (1.6%) had a prior history of coronary artery bypass surgery (CABG). Multivariate analysis for the outcome of suboptimal CAD risk management (composite of systolic blood pressure≥130 mmHg, glucose≥125 mg/dL (6.9 mmol/L) for diabetics, total cholesterol≥200 mg/dL (5.2 mmol/L), or current smoking; n=38,746/53,403, 72.5%) revealed older age (per year) (odds ratio (OR)=1.04, 95% confidence interval (CI) 1.03-1.04, P<0.0001), male gender (OR=1.40, 95% CI 1.34-1.47, P<0.0001), ACR≥30 mg/g (3.4 mg/mmol) (OR=1.66, 95% CI 1.55-1.79, P<0.0001), body mass index (per kg/m2) (OR=1.06, 95% CI 1.06-1.06, P<0.0001), CAD without a history of revascularization (OR=1.14, 95% CI 1.02-1.28, P=0.02) and care received by a nephrologist (OR=1.49, 95% CI 1.22-1.83, P<0.0001) were associated with worse risk factor control. Prior coronary revascularization and being under the care of a cardiologist were not associated with either improved or suboptimal risk factor control. CONCLUSIONS: Chronic kidney disease is associated with overall poor rates of CAD risk factor control.

Environmental Factors Driving Spatial Heterogeneity in Desert Halophile Microbial Communities.

Spatial heterogeneity in microbial communities is observed in all natural ecosystems and can stem from both adaptations to local environmental conditions as well as stochastic processes. Extremophile microbial communities inhabiting evaporitic halite nodules (salt rocks) in the Atacama Desert, Chile, are a good model ecosystem for investigating factors leading to microbiome heterogeneity, due to their diverse taxonomic composition and the spatial segregation of individual nodules. We investigated the abiotic factors governing microbiome composition across different spatial scales, allowing for insight into the factors that govern halite colonization from regional desert-wide scales to micro-scales within individual nodules. We found that water availability and community drift account for microbiome assembly differently at different distance scales, with higher rates of cell dispersion at the smaller scales resulting in a more homogenous composition. This trend likely applies to other endoliths, and to non-desert communities, where dispersion between communities is limited. At the intra-nodule scales, a light availability gradient was most important in determining the distribution of microbial taxa despite intermixing by water displacement via capillary action.

Contrast-induced acute kidney injury in renal transplant recipients after cardiac catheterization.

Renal transplant (RTX) recipients remain at high-risk for acute kidney injury (AKI) despite having improved renal function and quality of life after transplantation. We sought to identify the incidence and risk factors for contrast-induced AKI in RTX recipients after cardiac catheterization at our institute as identified by electronic records. After excluding patients on dialysis at time of procedure due to failed transplant and who did not have post-exposure creatinine values within 3 days, we reviewed 77 procedures on 57 patients. We studied one case per patient (the most recent procedure). Among the 57 patients, 42 were male, 42 were Caucasian and mean age was 58.2 +/- 10.1 years. Mean serum creatinine 24 h pre-procedure was 1.7 +/- 0.8 mg/dl. Contrast-induced AKI, defined as rise in serum creatinine of 25% or 0.5 mg/dl within 3 days post-catheterization, occurred in 9 procedures (15.8%). One procedure was complicated by AKI requiring dialysis. AKI occurred more frequently with use of low-osmolar contrast (ioxaglate or iohexol) in comparison with iso-osmolar contrast (iodixanol) (9/36 vs. 0/21, p = 0.019). Patients who received prophylactic N-acetylcysteine had lower incidence of AKI than those who did not (4/41 vs. 5/16, p = 0.046). Exact logistic regression analysis revealed odds ratio of developing AKI with use of low-osmolar vs. iso-osmolar contrast to be 7.747 (1.101 - yen); p = 0.0381). Contrast-induced AKI was common in RTX recipients after cardiac catheterization. Iso-osmolar contrast was associated with a lower risk of contrast-induced AKI in comparison with low-osmolar contrast.

Kidney's role in hypertension.

Hypertension is both the cause and effect of kidney disease. Together these two diseases have become epidemics in our society and are associated with an increased risk of cardiovascular events. Over the last several decades multiple clinical and transplant studies have shown the kidney to be an important determinant of essential hypertension. However, little is known about the direct mechanisms in which the kidney induces hypertension or why the blood pressure tends to rise in the failing kidney. This document provides a systematic analysis of peer-reviewed, published literature pertaining to the central role of the kidney in the development of essential hypertension in adults. We will describe the pathophysiology of essential hypertension and its relationship to chronic kidney disease and cardiovascular disease. Particular focus will be drawn to effects of sodium handling, the renin angiotensin aldosterone system, the sympathetic system and mediators of vascular tone in the development of kidney induced hypertension. In addition, the mediators which initiate and maintain the progression of chronic kidney disease, and how these factors are related in the development of hypertension will also be discussed. Finally, therapeutic strategies to treat individuals with chronic kidney disease in order to prevent the development of essential hypertension and lower their cardiovascular risk will be presented.

Effects of different ACE inhibitor combinations on albuminuria: results of the GUARD study.

Clinical practice guidelines recommend blockers of the renin-angiotensin system alone or in combination with other agents to reduce blood pressure and albuminuria in patients with type 2 diabetes. Dihydropyridine calcium channel blockers, however, may lower blood pressure but not albuminuria in these patients. Here we tested the hypothesis that combining an ACE inhibitor with either a thiazide diuretic or a calcium channel blocker will cause similar reductions in blood pressure and albuminuria in hypertensive type 2 diabetics. We conducted a double blind randomized controlled trial on 332 hypertensive, albuminuric type 2 diabetic patients treated with benazepril with either amlodipine or hydrochlorothiazide for 1 year. The trial employed a non-inferiority design. Both combinations significantly reduced the urinary albumin to creatinine ratio and sitting blood pressure of the entire cohort. The percentage of patients progressing to overt proteinuria was similar for both groups. When we examined patients who had only microalbuminuria and hypertension we found that a larger percentage of the diuretic and ACE inhibitor normalized their albuminuria. We conclude that initial treatment using benzaepril with a diuretic resulted in a greater reduction in albuminuria compared to the group of ACE inhibitor and calcium channel blocker. In contrast, blood pressure reduction, particularly the diastolic component, favored the combination with amilodipine. The dissociation between reductions in blood pressure and albuminuria may be related to factors other than blood pressure.

Low birth weight is associated with chronic kidney disease only in men.

The association of low birth weight and chronic kidney disease was examined in a screened volunteer population by the National Kidney Foundation's Kidney Early Evaluation Program. This is a free, community-based health program enrolling individuals aged 18 years or older with diabetes, hypertension, or a family history of kidney disease, diabetes, or hypertension. Self-reported birth weight was categorized and chronic kidney disease defined as an estimated glomerular filtration rate less than 60 ml per min per 1.73 m(2) or a urine albumin/creatinine ratio >or=30 mg/g. Among 12 364 participants, 15% reported a birth weight less than 2500 g. In men, significant corresponding odds ratios were found after adjustment for demographic characteristics and health conditions to this low birth weight and chronic kidney disease, but there was no association among women. There was no significant interaction between birth weight and race for either gender. Efforts to clinically understand the etiology of this association and potential means of prevention are essential to improving public health.

Breast conserving surgery for breast cancer involving the nipple.

We present two cases of invasive breast carcinoma with involvement of the dermis and epidermis of the nipple areolar complex (NAC), which were treated with an immediate breast reconstruction. Oncoplastic techniques were utilised in both cases: Latissimus Dorsi Mini Flap in the first and therapeutic reduction mammaplasty in the second. Both methods were used to fill the defect and also to recreate the NAC. We believe these techniques have an expanding role in the repertoire of surgical options for treating breast carcinoma.

The effect of weight loss after bariatric surgery on albuminuria.

BACKGROUND: Bariatric surgery achieves long-term weight loss in obese adults with improvement of diabetes and hypertension. Little is known about the effect of this weight loss on renal parameters. METHODS: We performed a retrospective study of 94 obese adults who had Roux-en-Y gastric bypass surgery with a mean 12-month follow-up. Baseline (preoperative) mean age was 49 years, 76% were female, 37 had blood pressure (BP) >or= 140/90 mmHg and 32 had Type 2 diabetes. 73 patients had normoalbuminuria (urine albumin creatinine ratio (ACR) <30 mg/g) while 21 had microalbuminuria (ACR 30<300 mg/g). RESULTS: At follow-up (postoperative), we observed a decrease in mean body weight (133.6 to 97.9 kg, p<0.0001), mean hemoglobin A1c (6.3 to 5.6%, p<0.0001) and mean systolic blood pressure (132.7 to 114.0 mmHg, p<0.0001). There was a significant reduction in ACR (median with interquartile range) from 9.5 (5-28) to 5.5 (3-10) mg/g, p < 0.0001. Fewer patients had microalbuminuria (22.2 to 6.2%, p=0.004) after surgery. Subgroup analysis revealed that significant decrease in ACR was present in the 32 patients with diabetes (16.5 (5-67) to 6.0 (4-11) mg/g, p=0.001) and in the 37 patients with metabolic syndrome (8.0 (5-16) to 6.0 (3-13) mg/g, p=0.012), while 25 patients with obesity alone had a lower ACR (6.5 (4-13) to 4.5 (3-8) mg/g, p=0.270). Multiple linear regression analysis showed change in hemoglobin A1c (p=0.011) and baseline level of ACR (p<0.0001) to be significantly associated with change in ACR. CONCLUSION: We conclude that obese adults have a reduction in albuminuria after surgical weight loss, most importantly in patients with diabetes or metabolic syndrome.

The pathophysiology of cardiac surgery-associated acute kidney injury (CSA-AKI).

Cardiac surgery associated acute kidney injury (CSA-AKI) is a significant clinical problem. Its pathogenesis is complex and multifactorial. It likely involved at least six major injury pathways: exogenous and endogenous toxins, metabolic factors, ischemia and reperfusion, neurohormonal activation, inflammation and oxidative stress. These mechanisms of injury are likely to be active at different times with different intensity and probably act synergistically. Because of such complexity and the small number of randomised controlled investigations in this field only limited recommendations can be made. Nonetheless, it appears important to avoid nephrotoxic drugs and desirable to avoid hyperglycemia in the peri-operative period. The duration of cardiopulmonary bypass should be limited whenever possible. Off-pump surgery, when indicated, may decrease the risk of AKI. Invasive hemodynamic monitoring focussed on attention to maintaining euvolemia, an adequate cardiac output and an adequate arterial blood pressure is desirable. Echocardiography may be useful in minimizing atheroembolic complications. The administration of N-acetylcysteine to protect the kidney from oxidative stress is not recommended. There is marked lack of randomised controlled trials in this field.

TESS DISCOVERY OF A TRANSITING SUPER-EARTH IN THE π MENSAE SYSTEM.

We report the detection of a transiting planet around π Men (HD 39091), using data from the Transiting Exoplanet Survey Satellite (TESS). The solar-type host star is unusually bright (V = 5.7) and was already known to host a Jovian planet on a highly eccentric, 5.7-year orbit. The newly discovered planet has a size of 2.04 ± 0.05 R ⊕ and an orbital period of 6.27 days. Radial-velocity data from the HARPS and AAT/UCLES archives also displays a 6.27-day periodicity, confirming the existence of the planet and leading to a mass determination of 4.82±0.85 M ⊕. The star's proximity and brightness will facilitate further investigations, such as atmospheric spectroscopy, asteroseismology, the Rossiter-McLaughlin effect, astrometry, and direct imaging.

Socioeconomic status is an important determinant of the use of invasive procedures after acute myocardial infarction in New York State.

BACKGROUND: Patient and hospital characteristics influence the use of invasive cardiac procedures. Whether socioeconomic status (SES) has an influence that is independent of these other determinants is unclear. The purpose of the present study was to examine the influence of household income as a measure of SES on the use of invasive cardiac procedures among a large group of patients with acute myocardial infarction. METHODS AND RESULTS: We analyzed administrative discharge data from 231 nonfederal acute care hospitals in New York State that involved 28 698 black or white inpatients with International Classification of Diseases, Ninth Revision, Clinical Modification code 410.XX in the principal diagnosis position between January 1 and December 31, 1995. Household income was derived from postal ZIP codes and census data. The use of cardiac catheterization, PTCA, CABG, and any revascularization procedure was examined across groups stratified by income. Patients who resided in lower-income neighborhoods were more often female or black, had a higher prevalence of coexistent illness, had a higher use of Medicaid insurance, and were less often admitted to urban hospitals or hospitals that provide on-site CABG and PTCA. Crude and adjusted odds ratios for catheterization, PTCA, CABG, and any revascularization procedure were related to income in a graded fashion. After adjustment, patients in the highest quintile of income were 22% more likely to undergo catheterization, 74% more likely to undergo PTCA, 48% more likely to undergo CABG, and 76% more likely to undergo any revascularization procedure than were patients in the lowest quintile. The difference in cardiac catheterization did not fully account for income-based differences in revascularization, because income remained a significant determinant of revascularization after accounting for whether a catheterization was performed. Even among patients treated in hospitals that provide on-site CABG and PTCA, income was a significant determinant of procedures. CONCLUSIONS: Lower-income patients hospitalized for acute myocardial infarction are more often female or black, have more coexisting illnesses, and are less often admitted to urban hospitals or hospitals that provide CABG and PTCA. Even after adjustment for these and other factors, lower income is a negative predictor of procedure use.

Ninety-minute exclusion of acute myocardial infarction by use of quantitative point-of-care testing of myoglobin and troponin I.

BACKGROUND: Diagnostic strategies with ECG and serum cardiac markers have been used to rule out acute myocardial infarction in 6 to 12 hours. The present study evaluated whether a multimarker strategy that used point-of-care measurement of myoglobin, creatine kinase (CK)-MB, and troponin I could exclude acute myocardial infarction in

A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial.

OBJECTIVES: The purpose of this study was to determine if early triage angiography with revascularization, if indicated, favorably affects clinical outcomes in patients with suspected acute myocardial infarction who are ineligible for thrombolysis. BACKGROUND: The majority of patients with acute myocardial infarction and other acute coronary syndromes are considered ineligible for thrombolysis and therefore are not afforded the opportunity for early reperfusion. METHODS: This multicenter, prospective, randomized trial evaluated in a controlled fashion the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n=201) with <24 h of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy consisting of aspirin, intravenous heparin, nitroglycerin, beta-blockers, and analgesics. RESULTS: In the triage angiography group, 109 patients underwent early angiography and 64 (58%) received revascularization, whereas in the conservative group, 54 (60%) subsequently underwent nonprotocol angiography in response to recurrent ischemia and 33 (37%) received revascularization (p=0.004). The mean time to revascularization was 27+/-32 versus 88+/-98 h (p=0.0001) and the primary endpoint of recurrent ischemic events or death occurred in 14 (13%) versus 31 (34%) of the triage angiography and conservative groups, respectively (45% risk reduction, 95% CI 27-59%, p=0.0002). There were no differences between the groups with respect to initial hospital costs or length of stay. Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality. CONCLUSIONS: Early triage angiography in patients with acute coronary syndromes who are not eligible for thrombolytics reduced the composite of recurrent ischemic events or death and shortened the time to definitive revascularization during the index hospitalization. Despite more frequent early revascularization after triage angiography, we found no long-term benefit in cardiac outcomes compared with conservative medical therapy with revascularization prompted by recurrent ischemia.