Abstract
Objective To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI). Background Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission. Methods NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke). Results Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12–24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12–24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637–1.733, p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (Conclusions In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved one-year cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients.
Highlights
Current European and American guidelines recommend angiography within 24 hours of hospitalisation for patients with non-STelevation myocardial infarction (NSTEMI). Key to these recommendations was the TIMACS trial (Timing of Intervention in Acute Coronary Syndromes) which found that invasive angiography within 24 hours of admission was associated with a reduced rate of recurrent ischemia at 6 months when compared with angiography ≥36 hours after admission [1]
Further support came from the RIDDLE-NSTEMI trial, which found that early angiography following NSTEMI was associated with reduced mortality/recurrent MI at both 30 days and 1 year when compared with a delayed strategy [2]
After 2 :1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12–24 h group presented no significant differences in main baseline clinical characteristics (Table 1). e median follow-up time was 365.2 days (IQR 358.0–365.2) in both the 12 h and 12–24 h
Summary
Current European and American guidelines recommend angiography within 24 hours of hospitalisation for patients with non-STelevation myocardial infarction (NSTEMI). Key to these recommendations was the TIMACS trial (Timing of Intervention in Acute Coronary Syndromes) which found that invasive angiography within 24 hours of admission was associated with a reduced rate of recurrent ischemia at 6 months when compared with angiography ≥36 hours after admission [1]. Jobs et al analysed data from eight studies (including TIMACS and RIDDLE-NSTEMI) and found reduced 6-month mortality among NSTEMI patients treated with an early invasive strategy [4]
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