Why some patients with acute coronary syndrome hospitalized in a university tertiary centre do not undergo coronary angiography? Results from the AHEAD ACS registry

Abstract

BackgroundTo evaluate in-hospital and long-term mortality of patients with acute coronary syndromes (ACS) not having selective coronary angiography (CAG) during hospitalization and to analyze the reasons for conservative approach. Methods and patientsA single-centre retrospective study using registry data. Over the period from January 2005 to April 2009, a total of 193 ACS patients did not have in-hospital CAG. Fifty-five (28.5%) patients had recent CAG (within the last 12 months) or the procedure was planned after discharge (invasive group “I”). In 138 (71.5%) patients, CAG was not considered at all (conservative approach, group “C”). These subgroups were compared in terms of in-hospital parameters and long-term mortality. ResultsST-segment elevation myocardial infarction (STEMI) was diagnosed in 50 (25.9%) patients. The most frequent reasons for not performing CAG included serious comorbidities affecting the prognosis (22%) and pharmacological stabilization in very old individuals with non-STEMI (21%). One in ten (11%) patients died before the CAG was performed, the same proportion of patients refused to have CAG or had a long ischaemia time (STEMI subgroup). A temporary contraindication to CAG was found in 8%, a recent CAG finding not suitable for revascularization in 8%, while a limiting neurological disease was present in 6% of patients. In-hospital mortality was 30.1%, being higher in Group C (34.1% vs. 20.0%; p=0.049), 6-year mortality was as high as 78.8%, also with higher rates in Group C (86.2% vs. 60.2%; p<0.001). Patients receiving conservative therapy were older, with a higher proportion of limiting comorbidities that contraindicated CAG, and had a more serious course of hospitalization. ConclusionThe most common reasons for not performing CAG in ACS patients included advanced age, serious and often extra-cardiac comorbidities, and a complicated hospitalization course. The short- and long-term mortality rates in these patients are high.