Patients Admitted With Non-ST-Segment Elevation ACS
Patients Admitted With Non-ST-Segment Elevation ACS
Objective: We investigated the impact of the duration from hospital admission to coronary angiography on the outcome of patients admitted with non ST-segment elevation acute coronary syndromes (NSTE-ACS).
Background: Invasive risk stratification in patients with acute coronary syndromes (ACS) has been shown to improve outcome in contemporary studies. It is unclear whether early coronary angiography is better than initial medical therapy with later angiography.
Methods: We performed an analysis of patients admitted to a tertiary coronary intensive care unit (CICU) with NSTE-ACS and had coronary angiography performed during the same hospitalization. Patients were categorized into three groups based on the time-to-angiography: same-day, 1 to 2 days, and > 2 days. The baseline clinical features, angiography results, 30-day, 6-month cardiovascular outcome and 3-year mortality rate were compared between the groups before and after adjusting for confounding variables.
Results: A total of 836 fulfilled the inclusion criteria. Patients undergoing angiography > 2 days had a higher incidence of 3-vessel disease (45.7% vs. 31.7%, p < 0.001), underwent less percutaneous interventions at the time of the angiography (41.6% vs. 56.7%, p < 0.001), and more frequent coronary artery bypass surgery (9.9% vs. 15.3%, p = 0.05). Patients undergoing late invasive risk stratification (> 2 days) had increased 3-year mortality (OR 2.12, 95% CI 1.03–4.35, p = 0.04) after adjusting for confounding variables.
Conclusion: In patients with NSTE-ACS and no contraindication to angiography, delayed angiography of more than 2 days of presentation was associated with increased mortality at 3 years.
The current American College of Cardiology/American Heart Association guidelines recommend coronary angiography and revascularization for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and high-risk clinical features. This advantage of invasive approach is suggested by many contemporary randomized clinical trials demonstrating reduced death, myocardial infarction (MI), and recurrent angina in patients undergoing early angiography versus a conservative or ischemia driven strategy. Based on these data and the widespread availability of cardiac catheterization, it is not surprising that more than 60% of hospitalized patients with NSTE-ACS in United States hospitals undergo angiography within one week of hospital presentation.
However, clinical trials have not addressed the optimal timing of coronary angiography following hospital admission for NSTE-ACS. Recent analysis from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) study failed to show benefit of early invasive strategy on death, myocardial infarction (MI), or rehospitalization. On the other hand, data from the single-center Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-COOL) trial suggest benefit from very early coronary angiography of ACS patients within six hours of presentation compared to delayed angiography at three to five days. However, most patients with ACS do not present to the hospital within six hours of symptoms and, in these patients, it is unclear whether early coronary angiography is better than initial medical therapy and delayed angiography. We therefore investigated the impact of the duration from hospital admission to coronary angiography on the outcome of patients admitted with NSTE-ACS.
Objective: We investigated the impact of the duration from hospital admission to coronary angiography on the outcome of patients admitted with non ST-segment elevation acute coronary syndromes (NSTE-ACS).
Background: Invasive risk stratification in patients with acute coronary syndromes (ACS) has been shown to improve outcome in contemporary studies. It is unclear whether early coronary angiography is better than initial medical therapy with later angiography.
Methods: We performed an analysis of patients admitted to a tertiary coronary intensive care unit (CICU) with NSTE-ACS and had coronary angiography performed during the same hospitalization. Patients were categorized into three groups based on the time-to-angiography: same-day, 1 to 2 days, and > 2 days. The baseline clinical features, angiography results, 30-day, 6-month cardiovascular outcome and 3-year mortality rate were compared between the groups before and after adjusting for confounding variables.
Results: A total of 836 fulfilled the inclusion criteria. Patients undergoing angiography > 2 days had a higher incidence of 3-vessel disease (45.7% vs. 31.7%, p < 0.001), underwent less percutaneous interventions at the time of the angiography (41.6% vs. 56.7%, p < 0.001), and more frequent coronary artery bypass surgery (9.9% vs. 15.3%, p = 0.05). Patients undergoing late invasive risk stratification (> 2 days) had increased 3-year mortality (OR 2.12, 95% CI 1.03–4.35, p = 0.04) after adjusting for confounding variables.
Conclusion: In patients with NSTE-ACS and no contraindication to angiography, delayed angiography of more than 2 days of presentation was associated with increased mortality at 3 years.
The current American College of Cardiology/American Heart Association guidelines recommend coronary angiography and revascularization for patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and high-risk clinical features. This advantage of invasive approach is suggested by many contemporary randomized clinical trials demonstrating reduced death, myocardial infarction (MI), and recurrent angina in patients undergoing early angiography versus a conservative or ischemia driven strategy. Based on these data and the widespread availability of cardiac catheterization, it is not surprising that more than 60% of hospitalized patients with NSTE-ACS in United States hospitals undergo angiography within one week of hospital presentation.
However, clinical trials have not addressed the optimal timing of coronary angiography following hospital admission for NSTE-ACS. Recent analysis from the Treat angina with Aggrastat and determine Cost of Therapy with an Invasive or Conservative Strategy-Thrombolysis in Myocardial Infarction 18 (TACTICS-TIMI 18) study failed to show benefit of early invasive strategy on death, myocardial infarction (MI), or rehospitalization. On the other hand, data from the single-center Intracoronary Stenting with Antithrombotic Regimen Cooling-Off (ISAR-COOL) trial suggest benefit from very early coronary angiography of ACS patients within six hours of presentation compared to delayed angiography at three to five days. However, most patients with ACS do not present to the hospital within six hours of symptoms and, in these patients, it is unclear whether early coronary angiography is better than initial medical therapy and delayed angiography. We therefore investigated the impact of the duration from hospital admission to coronary angiography on the outcome of patients admitted with NSTE-ACS.
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