Early invasive versus early conservative strategy in non-ST-elevation acute coronary syndrome: An outcome research study.

BACKGROUND: An early invasive strategy (EIS) has been shown to yield a better clinical outcome than an early conservative strategy (ECS) in patients with non-ST-elevation acute coronary syndromes (NSTEACSs), particularly in those at higher risk according to the GRACE risk score. However, findings of the clinical trials have not been confirmed in registries. OBJECTIVE: To investigate the outcome of patients with NSTEACS treated according to an EIS or a ECS in a real-world all-comers outcome research study. METHODS: The primary hypothesis of the study was the non-inferiority of an ECS in comparison with an EIS as to a combined primary end-point of death, non-fatal myocardial infarction and hospital readmission for acute coronary syndromes at one year. Participating centres were divided into two groups: those with a pre-specified routine EIS and those with a pre-specified routine ECS. Two statistical analyses were performed: a) an 'intention to treat' analysis: all patients were considered to be treated according to the pre-specified routine strategy of that centre; b) a 'per protocol' analysis: patients were analysed according to the actual treatment applied. Cox model including propensity score correction was applied for all analyses. RESULTS: The intention to treat analysis showed an equivalence between EIS and ECS (11.4% vs. 11.1%) with regard to the primary end-point incidence at one year. In the three subgroups of patients according to the GRACE risk score (⩽ 108, 109-140, > 140), EIS and ECS confirmed their equivalence (5.3% vs. 3.9%, 8.4% vs. 7.6%, and 20.3% vs. 20.9%, respectively). When the per protocol analysis was applied, a reduction of the primary end-point at one year with EIS vs. ECS was demonstrated (6.2% vs. 15.3%, p=0.021); analysis of the subgroups according to the GRACE risk score numerically confirmed these data (3.1% vs. 6.5%, 5.1% vs. 10.0%, and 10.8% vs. 24.5%, respectively). CONCLUSIONS: In a real-life registry of all-comers NSTEACS patients, ECS was non-inferior to EIS; however, when EIS was applied according to clinical judgement, a reduction of clinical events at one year was demonstrated.

[Chest pain in women: a multicenter study of the National Association of Hospital Cardiologists (ANMCO) of the Lazio Region]. / Il dolore toracico nella donna: studio multicentrico della Sezione dell'ANMCO della Regione Lazio (progetto 3D).

BACKGROUND: Chest pain is an extremely common symptom in women, but several previous studies have suggested that in women this complaint is more frequently underdiagnosed than in men. The aim of this multicenter study proposed by the National Association of Hospital Cardiologists (ANMCO) was to analyze the clinical regimen adopted for women admitted to a public hospital of the Lazio Region for chest pain during a short period of time (only 30 days). METHODS: Between March 1 and March 31, 2001, 747 women were admitted in the Emergency Department of 20 public hospitals in the Lazio Region for chest pain. The patients' age ranged between 40 to 80 years (mean age 61.4 +/- 12.6 years). An ECG was recorded in 727 (97.5%), 326 (44%) underwent cardiologic examination, blood analysis was performed for 584 (78%) and 66 (8.8%) were submitted to two-dimensional echocardiography. RESULTS: Of the 727 ECGs, 403 (56%) were defined as "normal" by a cardiologist and 324 (44%) "abnormal". Of the 747 women with chest pain, 446 (60%) were discharged from the Emergency Department; 2 died (0.2%), and 298 (40%) were hospitalized. Among the latter, 169 (56%) were submitted to echocardiography, 45 (16%) to the ECG effort test, 22 (6%) to stress echocardiography, 40 (11%) to coronary angiography (3 also to primary coronary angioplasty), 10 (3.3%) to esophagogas-troduodenoscopy, and 68 (23%) to several non-cardiologic exams. The final diagnosis was atypical chest pain in 336 (45%), acute myocardial infarction in 60 (6.7%), paroxysmal atrial fibrillation in 42 (5.6%), typical angina in 60 (10.6%), aortic dissection in 3 (0.4%), pericarditis in 7 (0.9%), hypertensive crisis in 80 (11%), gastritis in 27 (3.6%), anxiety in 15 (2%), and a surgical or orthopedic diagnosis in 107 (14%). Two patients (0.2%) died. During follow-up (6 months) cardiac events occurred in 7.6% of 446 women discharged from the Emergency Department. CONCLUSIONS: This study demonstrated that the diagnostic tests are underutilized in women with chest pain, even compared to previous studies including male and female subjects. For women presenting with chest pain, the use of non-invasive tests with the best prognostic impact should be increased.