Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a 'real world' prospective registry.

BACKGROUND: An early invasive strategy (EIS) is recommended in high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), defined as coronary angiography (CAG), within 24 h of admission. The aim of the present study is to investigate guideline adherence, patient characteristics associated with timing of the intervention and clinical outcome. METHODS: In a prospective registry, the use and timing of CAG and the characteristics and clinical outcome associated with timing were evaluated in high-risk ACS patients. The outcome of early versus delayed invasive strategy (DIS) was compared. RESULTS: Between 2006 and 2014, 2,299 high-risk NSTE-ACS patients were included. The use of CAG increased from 77% in 2006 to 90% in 2014 (p trend <0.001) together with a decrease of median time to CAG from 23.3 to 14.5 h (p trend <0.001) and an increase of patients undergoing EIS from 50 to 60% (p trend = 0.002). Patient factors independently related to DIS were higher GRACE risk score, higher age and the presence of comorbidities. No difference was found in incidence of mortality, reinfarction or bleeding at 30-day follow-up. All-cause mortality at 1­year follow-up was 4.1% vs 7.0% in EIS and DIS respectively (hazard ratio 1.67, 95% confidence interval 1.12-2.49) but was comparable after adjustment for confounding factors. CONCLUSION: The percentage of high-risk NSTE-ACS patients undergoing CAG and EIS has increased in the last decade. In contrast to the guidelines, patients with a higher risk profile are less likely to undergo EIS. However, no difference in outcome after 30 days and 1 year was found after multivariate adjustment for this higher risk.

Early invasive versus selectively invasive strategy in patients with non-ST-segment elevation acute coronary syndrome: impact of age.

BACKGROUND: It is unclear whether the benefits of an early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS) equally apply to younger and older individuals. Elderly patients are generally less likely to undergo EIS when compared with younger patients. OBJECTIVES: We conducted a meta-analysis to compare the benefit of an EIS versus a selectively invasive strategy (SIS) in patients with NSTEACS. We tested the hypothesis that the magnitude of benefit of an EIS over a SIS mainly applies to older individuals. METHODS: We extracted data from randomized controlled trials (RCTs) identified through search methodology filters. The primary outcome of the analysis was the composite of all-cause death and myocardial infarction (MI). Secondary outcomes were death and MI taken alone and re-hospitalization. RESULTS: Nine trials (n = 9,400 patients) were eligible. The incidence of the composite end-point of MI and all-cause death was 16.0% with the EIS and 18.3% with the SIS (OR: 0.85, 95% CI: 0.76-0.95). The incidence of MI was 8.4% with the EIS and 10.9% with the SIS (OR: 0.75, 95% CI: 0.66-0.87). Similar results were obtained for rehospitalization (OR: 0.71, 95% CI: 0.55-0.90). The incidence of all-cause death did not differ between the two groups. The EIS reduced the composite end-point and re-hospitalization to a greater extent in elderly than in younger patients (P for interaction = 0.044 and <0.0001, respectively). These findings were confirmed in meta-regression analyses. CONCLUSIONS: In patients with NSTEACS, a routine EIS reduces the risk of rehospitalization and the composite end point of recurrent MI and death to a greater extent in elderly than in younger individuals.

[Predictors of the use of the early invasive strategy in women with non-ST-elevation acute coronary syndrome]. / Predictores del uso de la estrategia invasiva precoz en mujeres con síndrome coronario agudo sin elevación de ST.

OBJECTIVE: To identify determinants associated to an early invasive strategy in women with acute coronary syndromes without ST elevation (NSTE-ACS). DESIGN: A retrospective cohort study was made. Crude and adjusted analysis of the performance of the early invasive strategy using logistic regression. SETTING: Coronary Units enrolled in 2010 - 2011 in the ARIAM-SEMICYUC registry. PATIENTS: A total of 440 women with NSTE-ACS were studied. Sixteen patients were excluded due to insufficient data, together with 58 patients subjected to elective coronary angiography (> 72 h). VARIABLES ANALYZED: Demographic parameters, coronary risk factors, previous medication, comorbidity. Clinical, laboratory, hemodynamic and electrocardiographic data of the episode. RESULTS: Women treated conservatively were of older age, had oral anticoagulation, diabetes, previous coronary lesions, and heart failure (p<0.005), increased baseline bleeding and ischemic risk (p=0.05) and a higher heart rate upon admission (p<0.05). After adjustment, only age > 80 years (OR 0.48, 95% CI 0.27 to 0.82, p=0.009), known coronary lesions (OR 0.47, 95% CI 0.26-0.84, p=0.011), and heart rate (OR 0.98, 95% CI 0.97-0.99, p=0.003) were independently associated to conservative treatment. Smoking (OR 2.50, 95% CI 1.20 to 5.19, p=0.013) and high-risk electrocardiogram (OR 2.96, 95% CI 1.72 to 4.97, p<0.001) were associated to the early invasive strategy. The exclusion of early deaths (<24 h) did not alter these results. CONCLUSIONS: In women with NSTE ACS, smoking and a high-risk electrocardiogram upon admission were independent factors associated to the early invasive strategy. Previous coronary lesions, age > 80 years and increased heart rate were independent factors associated to conservative treatment.

Early Invasive Strategy for Octogenarians and Nonagenarians With Acute Myocardial Infarction.

Background: Older adults with acute myocardial infarction (AMI) are currently a rapidly growing population. However, their clinical presentation and outcomes remain unresolved. Methods and Results: A total of 268 consecutive AMI patients were analyzed for clinical characteristics and outcomes with major adverse cardiovascular events (MACE) and all-cause mortality within 1 year. Patients aged ≥80 years (Over-80; n=100) were compared with those aged ≤79 years (Under-79; n=168). (1) Primary percutaneous coronary intervention (PCI) was frequently and similarly performed in both the Over-80 group and the Under-79 group (86% vs. 89%; P=0.52). (2) Killip class III-IV (P<0.01), in-hospital mortality (P<0.01), MACE (P=0.03) and all-cause mortality (P<0.01) were more prevalent in the Over-80 group than in the Under-79 group. (3) In the Over-80 group, frail patients showed a significantly worse clinical outcome compared with non-frail patients. (4) Multivariate analysis revealed Killip class III-IV was associated with MACE (odds ratio [OR]=3.51; P=0.02) and all-cause mortality (OR=9.49; P<0.01) in the Over-80 group. PCI was inversely associated with all-cause mortality (OR=0.13; P=0.02) in the Over-80 group. Conclusions: The rate of primary PCI did not decline with age. Although octogenarians/nonagenarians showed more severe clinical presentation and worse short-term outcomes compared with younger patients, particularly in those with frailty, the prognosis may be improved by early invasive strategy even in these very old patients.

Impact of Early Invasive Strategy on Left Ventricular Function Recovery in Acute Myocardial Infarction Patients in Pakistan.

Background Acute myocardial infarction (AMI) is a leading cause of morbidity and mortality worldwide, particularly in low- and middle-income countries like Pakistan, where healthcare resources are limited. Early Invasive Strategy (EIS), typically involving percutaneous coronary intervention (PCI), has been shown to improve outcomes in AMI patients. However, the effectiveness of EIS in resource-limited settings, such as Pakistan, remains under-explored. Objective This prospective observational cohort study aimed to assess the impact of an Early Invasive Strategy (EIS) on left ventricular (LV) function recovery in acute myocardial infarction (AMI) patients in Pakistan. The primary objective was to measure the change in left ventricular ejection fraction (LVEF) over six months. Secondary objectives included evaluating mortality, rehospitalization rates, and incidences of major adverse cardiovascular events (MACE). Multivariate regression analysis was employed to adjust for potential confounders. Methods The study was conducted from January to December 2023 at the National Institute of Cardiovascular Diseases (NICVD) satellite centers in Sukkur, Nawab Shah, and Khairpur. A total of 300 AMI patients presenting within 24 hours of symptom onset were included. Participants were divided into two groups: the EIS group (n = 150) received percutaneous coronary intervention (PCI) within 24 hours of admission, while the delayed treatment group (n = 150) received standard therapy, with invasive procedures performed after 24 hours if clinically indicated. Data were collected at baseline, during hospitalization, and at three- and six-months post-AMI. Results The EIS group demonstrated a significantly greater improvement in LVEF compared to the delayed treatment group (13.1% [95% CI, 10.8%-15.4%] vs. 7.5% [95% CI, 5.8%-9.2%], p < 0.001). Mortality was lower in the EIS group (3% [n = 4] vs. 9% [n = 13], p = 0.01), as were rehospitalizations for heart failure (7% [n = 10] vs. 14% [n = 21], p = 0.02) and incidences of MACE (8% [n = 12] vs. 16% [n = 24], p = 0.01). Multivariate regression analysis confirmed that EIS was independently associated with better LVEF improvement (coefficient = 5.78 [95% CI, 4.21-7.35], p < 0.001). Conclusion Early invasive treatments significantly enhance left ventricular function recovery and reduce mortality and rehospitalization rates in AMI patients in Pakistan. These findings advocate for the implementation of timely PCI interventions in resource-limited settings to improve clinical outcomes, particularly emphasizing cost-effectiveness and the availability of PCI.

Acute Coronary Syndrome: Treatment Strategies and Outcomes in Patients Admitted to a Tertiary Care Hospital in Palestine.

Background: Acute coronary syndrome (ACS) is the leading cause of death worldwide despite advances in treatment and prevention measures. This study aimed to explore ACS treatment strategies (ischemia-guided vs early invasive) and risk factors among patients diagnosed with ACS in a tertiary care hospital in Palestine and to evaluate related outcomes regarding future events and standard clinical guidelines. Methods: This retrospective cohort study reviewed patient data from a Palestinian medical hospital. The study included 255 patients ≥ 18 years who were hospitalized between January 2021 and December 2021 and diagnosed with ACS. The data were analyzed using the Statistical Package for Social Science (SPSS). Results: 71% of the participants were males. The mean age was 59.59±11.56 years. Smoking, diabetes, and hypertension were the most common risk factors. Unstable angina (UA) was the most prevalent ACS type, accounting for 43.1% (110) of cases, whereas NSTEMI accounted for 39.2% (100) and STEMI accounted for 17.6% (45) of cases. An ischemic-guided strategy approach was used in 71% (181) of the patients. Upon discharge, the most prescribed medication classes were antiplatelets (97.6%), statins (87.1%), PPIs (72.5%), and antihypertensives (71.8%). Treatment strategies were selected according to the clinical guidelines for most ACS types. Conclusion: ACS management in Palestine continues to evolve to overcome barriers, decrease patient mortality, and decrease hospital stay. UA and NSTEMI were the most common ACS diagnoses at admission, and the ischemic strategy was the most common modality. The findings of this study call for an increased awareness of CVD risk factors, resource availability, and adherence to clinical guidelines to improve patient outcomes and community health.

Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain.

INTRODUCTION AND OBJECTIVES: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

Stepwise relationship between delay in percutaneous coronary intervention and long-term mortality in patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: Current guidelines recommend coronary catheterization in patients with non-ST- -segment elevation myocardial infarction (NSTEMI) within 24 hours of hospital admission. However, whether there is a stepwise relationship between the time to percutaneous coronary intervention (PCI) and long-term mortality in patients with NSTEMI treated invasively within 24 hours of admission has not been established yet. AIMS: The study aimed to evaluate the association between door-to-PCI time and all-cause mortality at 12 and 36 months in NSTEMI patients presenting directly to a PCI-capable center who underwent PCI within the first 24 hours of hospitalization. METHODS: We analyzed data of patients hospitalized for NSTEMI between 2007-2019, included in the nationwide registry of acute coronary syndromes. Patients were stratified into twelve groups based on 2-hour intervals of door-to-PCI time. The mortality rates of patients within those groups were adjusted for 33 confounding variables by the propensity score weighting method using overlap weights. RESULTS: A total of 37 589 patients were included in the study. The median age of included patients was 66.7 (interquartile range [IQR], 59.0-75.8) years; 66.7% were male, and the median GRACE (Global Registry of Acute Coronary Events) score was 115 (98-133). There were increased 12-month and 36-month mortality rates in consecutive groups of patients stratified by 2-hour door-to-PCI time intervals. After adjustment for patient characteristics, there was a significant positive correlation between the time to PCI and the mortality rates (rs = 0.61; P = 0.04 and rs = 0.65; P = 0.02 for 12-month and 36-month mortality, respectively). CONCLUSIONS: The longer the door-to-PCI time, the higher were 12-month and 36-month all-cause mortality rates in NSTEMI patients.

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox.

Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

Adopting an early invasive strategy for non-ST-elevation myocardial infarction: Analysis of the Portuguese Registry on Acute Coronary Syndromes. / Adoção da estratégia invasiva precoce no enfarte agudo do miocárdio sem supra desnivelamento de ST: análise dos resultados do Registo Nacional de Síndromas Coronárias Agudas.

INTRODUCTION: In patients with non-ST-elevation myocardial infarction (NSTEMI), the best timing for coronary angiography is not definitely established, although it is recognized that in high-risk patients it should be performed within the first 24 hours. The aim of this work was to describe the evolution over time of the use of an invasive strategy in the treatment of NSTEMI and in-hospital mortality. METHODS: We performed a retrospective analysis of patients admitted with NSTEMI included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between 2002 and 2015. The annual proportion of patients undergoing coronary angiography and the time from admission to coronary angiography were assessed, as were changes in mortality and length of stay. RESULTS: A total of 18 639 patients with NSTEMI were included in the ProACS registry between 2002 and 2015. Over this period there were significant increases in the proportion of patients undergoing coronary angiography (from 52.0 to 83.6%) and angioplasty (from 23.3 to 53.0%), as well as in the proportion of patients who underwent coronary angiography within 24 hours of admission (from 21.0 to 48.1%). In-hospital mortality decreased in those aged over 74 years (from 9.5 to 3.7%) and in males. CONCLUSIONS: The progressive adoption of an invasive strategy, particularly an early one (within 24 hours), was accompanied by a reduction in in-hospital mortality. Since coronary angiography is performed late (>24 hours) in half of NSTEMI patients, these patients could benefit from initiatives similar to Stent for Life.

Early Invasive Strategy and In-Hospital Survival Among Diabetics With Non-ST-Elevation Acute Coronary Syndromes: A Contemporary National Insight.

BACKGROUND: There are limited data on the merits of an early invasive strategy in diabetics with non-ST-elevation acute coronary syndrome, with unclear influence of this strategy on survival. The aim of this study was to evaluate the in-hospital survival of diabetics with non-ST-elevation acute coronary syndrome treated with an early invasive strategy compared with an initial conservative strategy. METHODS AND RESULTS: The National Inpatient Sample database, years 2012-2013, was queried for diabetics with a primary diagnosis of non-ST-elevation acute coronary syndrome defined as either non-ST-elevation myocardial infarction or unstable angina (unstable angina). An early invasive strategy was defined as coronary angiography±revascularization within 48 hours of admission. Propensity scores were used to assemble a cohort managed with either an early invasive or initial conservative strategy balanced on >50 baseline characteristics and hospital presentations. Incidence of in-hospital mortality was compared in both groups. In a cohort of 363 500 diabetics with non-ST-elevation acute coronary syndrome, 164 740 (45.3%) were treated with an early invasive strategy. Propensity scoring matched 21 681 diabetics in both arms. Incidence of in-hospital mortality was lower with an early invasive strategy in both the unadjusted (2.0% vs 4.8%; odds ratio [OR], 0.41; 95% CI, 0.39-0.42; P<0.0001) and propensity-matched models (2.2% vs 3.8%; OR, 0.57; 95% CI, 0.50-0.63; P<0.0001). The benefit was observed across various subgroups, except for patients with unstable angina (Pinteraction=0.02). CONCLUSIONS: An early invasive strategy may be associated with a lower incidence of in-hospital mortality in patients with diabetes. The benefit of this strategy appears to be superior in patients presenting with non-ST-elevation myocardial infarction compared with unstable angina.

Timing of invasive strategy in NSTE-ACS patients and effect on clinical outcomes: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Previous randomized controlled trials (RCTs) have produced conflicting results on the effects of early versus delayed invasive strategy in NSTE-ACS patients. OBJECTIVES: To perform up to date meta-analysis on the pooled data sample comparing early versus delayed invasive strategy, and to explore potential causes for the observed high statistical heterogeneity. METHODS: MEDLINE via Pubmed, Central, Google Scholar, Clinical Trials Registry, Current controlled study and ClinicalTrials.gov registry and relevant conference proceedings were searched. RCTs were included that directly compared early versus delayed invasive strategy and reported rates of death, new myocardial infarction (MI) and/or recurrent ischemia. RESULTS: 10 RCTs with 6089 patients were included. Time to coronary angiography varied from 0.5 to 24 h in the early and from 20.5 to 86 h in the delayed group. Meta-analysis showed no significant difference in mortality (OR = 0.83, 95%CI 0.64-1.08, P = 0.16), and similar new MI rates (OR = 1.02, 95%CI 0.63-1.64, P = 0.94). The rate of recurrent ischemia was reduced in patients undergoing early coronary angiography (OR = 0.56, 95%CI 0.40-0.79, P = 0.001). Subgroup analysis indicated that the rate of new MI tended to depend on the study-specific endpoint definition (p for difference between subgroups 0.11), while a meta-regression revealed association of new MI rates with the within-study delay to coronary angiography (p = 0.05). CONCLUSION: Early invasive strategy appears to reduce the occurrence of recurrent ischemia, but confers no mortality benefit. The true effect on the occurrence of new MI is obscured by the high between-study heterogeneity that stems mainly from non-uniform timing of early intervention and new MI definitions across the trials.

Non-ST-elevation myocardial infarction in the United States: contemporary trends in incidence, utilization of the early invasive strategy, and in-hospital outcomes.

BACKGROUND: There has been a paradigm shift in the definition of timing of early invasive strategy (EIS) for patients admitted with non-ST-elevation myocardial infarction (NSTEMI) in the last decade. Data on trends of EIS for NSTEMI and associated in-hospital outcomes are limited. Our aim is to analyze temporal trends in the incidence, utilization of early invasive strategy, and in-hospital outcomes of NSTEMI in the United States. METHODS AND RESULTS: We analyzed the 2002-2011 Nationwide Inpatient Sample databases to identify all patients ≥40 years of age with the principal diagnosis of acute myocardial infarction (AMI) and NSTEMI. Logistic regression was used for overall, age-, sex-, and race/ethnicity-stratified trend analysis. From 2002 to 2011, we identified 6 512 372 patients with AMI. Of these, 3 981 119 (61.1%) had NSTEMI. The proportion of patients with NSTEMI increased from 52.8% in 2002 to 68.6% in 2011 (adjusted odds ratio [OR; per year], 1.055; 95% confidence interval [CI], 1.054 to 1.056) in the overall cohort. Similar trends were observed in age-, sex-, and race/ethnicity-stratified groups. From 2002 to 2011, utilization of EIS at day 0 increased from 14.9% to 21.8% (Ptrend<0.001) and utilization of EIS at day 0 or 1 increased from 27.8% to 41.4% (Ptrend<0.001). Risk-adjusted in-hospital mortality in the overall cohort decreased during the study period (adjusted OR [per year], 0.976; 95% CI, 0.974 to 0.978). CONCLUSIONS: There have been temporal increases in the proportion of NSTEMI and, consistent with guidelines, greater utilization of EIS. This has been accompanied by temporal decreases in in-hospital mortality and length of stay.