Abstract
The timing of coronary angiography in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) remains a matter of debate. The relationship between the timing of invasive management and left ventricular function (LVF) is largely unknown. The An Immediate or Early Invasive Strategy in Non-ST-Elevation Acute Coronary Syndrome trial (OPTIMA-2) was a randomized controlled prospective open-label multicenter trial that randomized 249 NSTE-ACS patients to either an immediate (<3 h) invasive treatment strategy or an early strategy (12–24 h). Patients were pre-treated with a combination of aspirin, ticagrelor and fondaparinux. The aim of this prespecified sub-analysis was to assess (the recovery of) left ventricular function by analysing echocardiography data obtained <72 h after admission and at 30-day follow-up, for patients with a confirmed diagnosis of acute coronary syndrome. LVF was determined using ejection fraction (EF) and global longitudinal strain (GLS). Inter-observer variability was tested. No difference in the recovery of EF was found between an immediate and early strategy if the follow-up echocardiograms were compared to baseline: 2.5% (standard deviation (SD): 7.9) and 3.3% (SD: 8.5), p = 0.51, nor was there any difference in GLS recovery between the study groups: −0.8% (SD: 2.5) vs. −0.7% (SD 2.8) p = 0.82. If baseline and follow-up echocardiograms were compared, there was a similar but significant improvement in both EF and GLS in both separate study groups. An immediate invasive strategy in NSTE-ACS patients did not result in an improved left ventricular EF or GLS recovery compared with an early strategy.
Highlights
For non-ST-segment elevation acute coronary syndromes (NSTE-ACS) a routine invasive strategy is advised according to both the European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines [1,2]
If baseline data was compared, we found no difference in Left ventricular ejection fraction (LVEF) between the study groups, nor did we find any difference between the groups at 30-day follow-up LVEF (Table 2)
The improvement of LVEF over time was in accordance with the findings of our study, whereas in our study, follow-up echocardiography was performed at 30 days instead of 3 months
Summary
For non-ST-segment elevation acute coronary syndromes (NSTE-ACS) a routine invasive strategy is advised according to both the European Society of Cardiology (ESC) and American College of Cardiology (ACC)/American Heart Association (AHA) guidelines [1,2]. Several trials have evaluated a variety of different strategies regarding the timing of coronary angiography and the revascularization of clinically stabilized NSTE-ACS patients [3,4,5,6]. The “An Immediate or Early Invasive Strategy in Non-ST-Elevation Acute Coronary Syndrome trial” (OPTIMA-2) was designed to study the impact of the timing of an invasive strategy on the total infarct size combining both the effects of spontaneous myocardial infarction and periprocedural-related injury in patients presenting with NSTE-ACS, with the use of modern antiplatelet and anticoagulant therapy. No significant difference in infarct size (measured as area under the curve (AUC) of creatine kinase myocardial band (CKMB)) or clinical endpoints (death, non-fatal MI or new revascularization) was found between an immediate (
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