Early Invasive Group Research Articles

The long-term clinical benefit of early versus delayed invasive strategies in elderly patients with non-ST-segment elevation myocardial infarction who have undergone percutaneous coronary intervention

Abstract Background The data regarding long-term outcomes of early versus delayed invasive strategies in elderly patients who have undergone percutaneous coronary intervention (PCI) for non-ST-segment elevation myocardial infarction (NSTEMI) is limited. Purpose We aimed to investigate the long-term clinical benefit of early versus delayed invasive strategies in elderly patients who underwent PCI for NSTEMI. Methods From a nationwide, prospective, real-world registry of 13,104 patients with acute myocardial infarction (MI) who underwent PCI, 2818 elderly patients (aged ≥70 years) who underwent PCI for NSTEMI were included. Of these, 2299 patients were treated with an early invasive strategy (early invasive group), and 519 were treated later (delayed invasive group). The incidence of major adverse cardiac events (MACE; all-cause death, recurrent MI, any revascularization, stroke, readmission due to heart failure [HF], or definite/probable stent thrombosis [ST]) and the components of MACE were compared using multivariable Cox regression, propensity score (PS) matched, and PS-adjusted analyses. Results During a median follow-up of 1047 days, MACE, all-cause death, and cardiac death occurred in 1018 (36.1%), 660 (23.4%), and 423 patients (15.0%), respectively. The early invasive group showed significantly lower risks of MACE (entire: 35.0% vs. 41.2%, hazard ratio [HR] 0.77, 95% confidence interval [CI] 0.66-0.90, p=0.001; PS-matched: n=984, 33.3% vs. 40.8%, HR 0.75, 95% CI 0.62-0.91, p=0.005), all-cause death (entire: 22.5% vs. 27.4%, HR 0.76, 95% CI 0.63-0.92, p=0.004; PS-matched: 21.8% vs. 27.2%, HR 0.75, 95% CI 0.58-0.90, p=0.005), cardiac death (entire: 13.8% vs. 20.2%, HR 0.64, 95% CI 0.51-0.79, p<0.001; PS-matched: 13.1% vs. 19.4%, HR 0.67, 95% CI 0.55-0.86, p=0.011), and readmission due to HF (entire: 6.5% vs. 9.2%, HR 0.64, 95% CI 0.46-0.89, p=0.007; PS-matched: 6.7% vs. 9.4%, HR 0.68, 95% CI 0.51-0.96, p=0.017) than the delayed invasive group. There were no significant differences in the risks of recurrent MI, any revascularization, stroke, and definite/probable ST between the groups. Furthermore, in patients aged ≥80 years, the early invasive group had significantly reduced rates of MACE (42.9% vs. 49.5%, HR 0.71, 95% CI 0.55-0.91, p=0.039), all-cause death (31.7% vs. 39.0%, HR 0.71, 95% CI 0.55-0.92, p=0.010), and cardiac death (20.9% vs. 31.0%, HR 0.59, 95% CI 0.44-0.80, p=0.001) compared to the delayed invasive group. Conclusions In elderly patients with NSTEMI, an early invasive intervention strategy was associated with favorable long-term clinical outcomes compared to a delayed invasive intervention strategy.

The Cost-Effectiveness of Early Invasive Procedures for Acute Coronary Syndrome in Low-Income Regions: A Prospective Cohort Study in Pakistan.

Background Acute coronary syndrome (ACS) is a significant cause of mortality and morbidity globally, necessitating effective intervention strategies. Early invasive procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are often recommended for high-risk patients. However, their cost-effectiveness in low-income regions remains uncertain, particularly in Pakistan, where healthcare resources are limited. Objective This study aims to evaluate the cost-effectiveness of early invasive procedures compared to standard care for ACS in low-income regions of Pakistan. Methods We conducted a prospective cohort study from January 1, 2021, to January 31, 2021, at four major hospitals in Pakistan: Army Cardiac Center Combined Military Hospital (CMH) Lahore, National Institute of Cardiovascular Diseases in Karachi, Lady Reading Hospital in Peshawar, and Mardan Medical Complex. The participants included 436 patients diagnosed with ACS aged 18 years or older and presenting within 24 hours of symptom onset. The patients were divided into two groups: the early invasive procedure group (n = 218) and the standard care group (n = 218). The primary outcome was the 30-day mortality rate. Secondary outcomes included recurrent myocardial infarctions, hospital readmissions, healthcare costs, and procedural complications. Data were analyzed using SPSS version 25.0 (IBM SPSS Statistics, Armonk, NY), employing descriptive statistics, chi-square tests, independent t-tests, and Kaplan-Meier survival analysis. Results The early invasive procedure group showed a mortality rate of 18 (8%) compared to 33 (15%) in the standard care group, demonstrating a significant reduction in mortality (p = 0.01). Additionally, the average healthcare cost was significantly lower in the early invasive group, with mean costs of Pakistani rupee (PKR) 187,200 (US dollar {USD} 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Recurrent myocardial infarctions occurred in 11 (5%) of the early invasive group versus 26 (12%) in the standard care group (p < 0.05). Hospital readmission rates were lower in the early invasive group, 22 (10%) compared to 39 (18%) in the standard care group (p < 0.05). Healthcare costs were significantly lower in the early invasive group, with mean costs of PKR 187,200 (USD 1,200) compared to PKR 280,800 (USD 1,800) in the standard care group (p < 0.01). Conclusion Early invasive procedures for ACS significantly improve survival rates, reduce complications, and lower healthcare costs in low-income regions of Pakistan. These findings suggest that such strategies should be considered in resource-limited settings to optimize patient outcomes and healthcare resource utilization.

Optimal timing of revascularization for patients with non-ST segment elevation myocardial infarction and severe left ventricular dysfunction.

Optimal timing of revascularization for patients who presented with non-ST segment elevation myocardial infarction (NSTEMI) and severe left ventricular (LV) dysfunction is unclear. A total of 386 NSTEMI patients with severe LV dysfunction from the nationwide, multicenter, and prospective Korea Acute Myocardial Infarction Registry V (KAMIR-V) were enrolled. Severe LV dysfunction was defined as LV ejection fraction ≤ 35%. Patients with cardiogenic shock were excluded. Patients were stratified into two groups: PCI within 24 hours (early invasive group) and PCI over 24 hours (selective invasive group). Primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) including all-cause death, non-fatal MI, repeat revascularization, and stroke at 12 months after index procedure. Early invasive group showed higher incidence of in-hospital death (9.4% vs 3.3%, P = .036) and cardiogenic shock (11.5% vs 4.6%, P = .030) after PCI. Early invasive group also showed higher maximum troponin I level during admission (27.7 ± 44.8 ng/mL vs 14.9 ± 24.6 ng/mL, P = .001), compared with the selective invasive group. Early invasive group had an increased risk of 12-month MACCE, compared with selective invasive group (25.6% vs 17.1%; adjusted HR = 2.10, 95% CI 1.17-3.77, P = .006). Among NSTEMI patients with severe LV dysfunction, the early invasive strategy did not improve the clinical outcomes. This data supports that an individualized approach may benefit high-risk NSTEMI patients rather than a routine invasive approach.

Outcomes of early versus delayed invasive strategy in dialysis patients with non-ST-elevation acute coronary syndrome

Abstract Background The association of early invasive strategy with improved outcomes in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) was previously established, particularly those at high risk. This benefit has not been evaluated in dialysis patients presenting with NSTE-ACS. Purpose This study aimed to investigate the prognostic impact of early invasive strategy in maintenance dialysis patients with NSTE-ACS. Methods This is a retrospective analysis of 455 617 consecutive cardiac catheterizations performed at 30 cardiac centers in China between January 2015 and June 2021. Patients were excluded if they did not receive dialysis therapy or received dialysis for less than 3 months, had normal coronary anatomy, or were admitted repeatedly . Patients were dichotomized into two groups based on the time interval from admission to invasive assessment: early (within 24 hours) invasive and delayed (more than 24 hours) invasive groups. The primary outcome of interest was all-cause mortality during follow-up. Standard univariate and survival methods were used. Propensity score matching and inverse probability of treatment weighting were used to diminish baseline differences. Results Overall, 1 012 patients met the final criteria, with a mean age of 61.7±10.4 years, and 398 (39.3%) of them received early invasive treatment. After a median follow-up of 21.8 months (interquartile range 12.6-34.9 months), 334 (33.0%) deaths were identified. Similar all-cause mortality rate was observed in the early invasive group compared with delayed invasive group (33.9% vs. 31.7%, respectively). After adjusting for baseline risk factors, early invasive was not associated with reduced all-cause mortality (hazard ratio 0.86, 95% confidence interval 0.69-1.08, p=0.198). Similar results were identified in the propensity score matching cohort and inverse Probability of Treatment Weighting cohort. Furthermore, no significant interaction was observed between the timing of invasive assessment and the Global Registry of Acute Coronary Events risk score (≤140 vs.&amp;gt;140) on the risk of all-cause death (p for interaction =0.858). Conclusion This multicenter study demonstrated comparable all-cause mortality between early invasive and delayed invasive groups in dialysis patients with NSTE-ACS. These findings were inconsistent with previous studies on NSTE-ACS patients with normal renal function, and further prospective studies are needed to confirm.

A randomized multicenter trial to evaluate early invasive strategy for patients with acute ST-segment elevation myocardial infarction presenting 24-48 hours from symptom onset: Protocol of the RESCUE-MI study

For ST-segment elevation myocardial infarction (STEMI) patients presenting 24 to 48 hours from symptom onset, whether early invasive strategy should be performed still remains controversial. This is a prospective, open-label, multicenter, investigator initiated, randomized controlled trial (NCT04962178) to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset. A total of 366 patients will be included from 10 hospitals in mainland China. They will be randomly (1:1) divided into 2 groups: the early invasive strategy group (primary percutaneous coronary intervention, PPCI) and conservative strategy group (optimal medical therapy with primary PCI not performed). All patients will be followed for 1 month. The primary end point is myocardial infarction size on cardiac magnetic resonance (CMR). The secondary end points are as follows: (1) major adverse cardiovascular events (MACE), which is defined as a composite of cardiac death, recurrent myocardial infarction, ischemic driven target vessel revascularization and stroke; (2) other CMR end points, including microvascular obstruction, intramyocardial hemorrhage, myocardial area at risk, left ventricular ejection fraction, left ventricular end diastolic volume and left ventricular end systolic volume. This study is designed to evaluate the efficacy of early invasive strategy for STEMI patients within 24 to 48 hours of symptom onset and will add more evidence for clinical practice. ClinicalTrials.gov Identifier: NCT04962178. Registered on July 14, 2021.

The effect of early invasive strategy on mortality outcome in patients with chronic kidney disease presenting with non-ST segment elevation myocardial infarction

Abstract Background Current guidelines recommend an early invasive strategy for patients with non-ST segment elevation myocardial infarction (NSTEMI). Purpose To evaluate whether early invasive strategy is associated with better outcome among patients with chronic kidney disease (CKD). Methods Retrospective cohort analysis of consecutive patients with NSTEMI between 2008 and 2021. Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation. Invasively treated patients were dichotomized into early (&amp;lt;24 hours) and non-early groups. Mortality data was available for all patients from a national registry. Multivariate Cox regression models with interaction analysis were applied. Results Final study population comprised 7,107 NSTEMI patients, of whom 3,172 (45%) had eGFR &amp;lt;60 ml/min/1.73m2. 1,988 (28%) and 973 (14%) patients had eGFR under 45 and 30 ml/min/1.73m2, respectively. 3,529 (50%) patients were treated invasively, among them 1837 (52%) underwent early invasive strategy. Patients in the early invasive group were younger (64 vs. 68 years, p&amp;lt;0.001) and were less likely to have comorbidities including kidney disease. During a median follow-up of 3 years (IQR 1.2–5.2), 2,552 (36%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death was 50%, 15%, and 6% among patients in the conservative, non-early, and early invasive groups respectively (p Log-rank &amp;lt;0.001). Subgroup analysis of invasively managed patients showed that early invasive strategy was associated with a significant 32% reduced risk of death in a multivariate model (95% CI 0.56–0.82, p&amp;lt;0.001), but this associated benefit was modified by eGFR (p for interaction 0.045). The modification effect of CKD on the association of early invasive strategy with outcome was most pronounced among invasively treated patients with eGFR &amp;lt;45 ml/min/1.73m2, with no survival benefit for early invasive approach in these patients (HR 0.8, 95% CI 0.57–1.14, p=0.221 vs. HR 0.6 95% CI 0.45–0.72, p&amp;lt;0.001; p for interaction=0.046). Conclusion Among invasively treated NSTEMI patients, the benefit of early invasive strategy is modified by CKD, and limited to those with eGFR ≥45 ml/min/1.73m2. Funding Acknowledgement Type of funding sources: None.

Initial optimal medical therapy with or without invasive strategy for stable coronary disease: a meta-analysis and systematic review.

There is a persistent controversy regarding the benefit and timing of angiography in patients with stable coronary artery disease (CAD). With this meta-analysis of randomized controlled trials (RCTs) the advantages of initial invasive strategy and medical therapy compared with only medical therapy. We conducted a literature search of the following databases Pubmed/MEDLINE, Cochrane Library and Embase. Data was collected from all the RCTs that compared early invasive approach with medical therapy alone in treating stable CAD which was conducted by two independent authors. Primary outcomes were all-cause mortality and myocardial infarction (MI), while the secondary outcomes included major adverse cardiovascular events (MACE), cardiovascular mortality, cardiovascular hospitalization, hospitalization due to unstable angina and revascularization events. The Mantel-Haenszel random-effects model was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs). We included 15 RCTs (13 916 patients, mean age 63.1, 78.9% men). The early invasive strategy, compared with medical therapy alone, did not reveal a significant reduction in the incidence of all-cause mortality (RR, 0.94; 95% CI, 0.84-1.05, P = 0.30) or MI (RR, 0.93; 95% CI, 0.79-1.10, P = 0.42). Furthermore, the early invasive strategy did not reduce the incidence of cardiovascular mortality, cardiovascular hospitalization or the revascularization rate compared with medical therapy alone (P > 0.05). However, the incidence of MACE and hospitalization due to unstable angina were lower in patients treated with early invasive strategy (RR, 0.79; 95% CI, 0.63-0.99, P = 0.04), and (RR, 0.46; 95% CI, 0.32-0.67, P < 0.0001), respectively. Early invasive strategy with medical therapy did not reduce the incidence of all-cause mortality and MI when compared with medical therapy alone among patients with stable CAD with significant stenosis. However, there was a significant reduction in the incidence of MACE and hospitalization due to unstable angina in the early invasive group.

Optimal Timing of Intervention in NSTE-ACS Without Pre-Treatment: The EARLY Randomized Trial

ObjectivesThe aim of this study was to compare a delayed and a very early invasive strategy in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) without pre-treatment. BackgroundThe optimal delay of the invasive strategy in patients with NSTE-ACS remains debated and has never been investigated in patients not pre-treated with P2Y12–adenosine diphosphate receptor antagonists. MethodsA prospective, open-label, randomized controlled trial was conducted. Altogether, 741 patients presenting with intermediate- or high-risk NSTE-ACS intended for an invasive strategy were included. The modified intention-to-treat analysis was composed of 709 patients after 32 withdrew consent. Patients were randomized 1:1 to the delayed invasive group (DG) (n = 363) with coronary angiography (CA) performed 12 to 72 h after randomization or the very early invasive group (EG) (n = 346) with CA within 2 h. No pre-treatment with a loading dose of a P2Y12–adenosine diphosphate receptor antagonist was allowed before CA. The primary endpoint was the composite of cardiovascular death and recurrent ischemic events at 1 month, as determined by a blinded adjudication committee. ResultsMost patients had high-risk NSTE-ACS in both groups (93% in the EG vs. 92.5% in the DG). The median time between randomization and CA was 0 h (interquartile range [IQR]: 0 to 1 h) in the EG group and 18 h (IQR: 11 to 23 h) in the DG. The primary endpoint rate was significantly lower in the EG (4.4% vs. 21.3% in the DG; hazard ratio: 0.20; 95% confidence interval: 0.11 to 0.34; p < 0.001), driven by a reduction in recurrent ischemic events (19.8% vs. 2.9%; p < 0.001). No difference was observed for cardiovascular death. ConclusionsWithout pre-treatment, a very early invasive strategy was associated with a significant reduction in ischemic events at the time of percutaneous coronary intervention in patients with intermediate- and high-risk NSTE-ACS. (Early or Delayed Revascularization for Intermediate and High-Risk Non ST-Elevation Acute Coronary Syndromes; NCT02750579)

Timing of Percutaneous Coronary Intervention in Non-ST Elevation Acute Coronary Syndrome - Meta-Analysis and Systematic Review of Literature

BackgroundPercutaneous coronary intervention (PCI) is the standard procedure of care for most patients with non-ST elevation acute coronary syndrome (NSTE-ACS). However, the timing of PCI remains unclear. We performed this meta-analysis with available randomized controlled trials (RCTs) to compare early versus late coronary intervention in patients with NSTE-ACS. MethodA total of 13 RCTs were selected through PubMed/MEDLINE via OVID, EMBASE via OVID and Cochrane Central Register of Controlled Trials (inception to October 2018) search. Outcomes were analyzed using the relative risk (RR) and 95% CI. Pooled RRs were determined using M-H random-effects model, which can account for between study heterogeneity. ResultsWe included 13 RCTs with 11,972 patients were included. There were 7101 patients were randomized into early invasive group and 4871 in late invasive group. There was a significant decrease in myocardial infarction with long-term follow up in early invasive group compared to the delayed invasive group (RR 0.847 [95% CI 0.74–0.95], p = 0.009) with no difference in mortality between early and late invasive group (5.41% vs 6.49%, RR 0.882 [95% CI, 0.76–1.02]). On subgroup analysis, data was available from 6 RCTs for GRACE (Global Registry of Acute Coronary Events) score and 8 RCTs for elevated troponin. Early intervention led to decrease in adverse events in patients with elevated GRACE score > 140 (Mantel-Haenszel pooled RR 0.88 [95% CI 0.82–0.95], p-value 0.002) but no difference was seen in patients with elevated troponin. ConclusionIt can be postulated from these results that early invasive strategy leads to decrease in myocardial infarction but without significant decrease in mortality. In patients with elevated GRACE score (>140), early intervention did show a trend towards decrease in major adverse cardiac events, whereas in patients with elevated troponin alone, similar association was not observed. However, adequately powered randomized controlled trial is necessary to validate these findings.

Early versus delayed invasive strategy in patients with non-ST-elevation acute coronary syndrome and concomitant congestive heart failure

Although there are guidelines that recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) and concomitant congestive heart failure (CHF), optimal timing of the invasive strategy remains controversial. Among 2045 patients who were admitted owing to NSTE-ACS or CHF, 300 presented with NSTE-ACS and concomitant CHF. Of the 300 patients, we enrolled 160 patients for whom coronary angiography (CAG) during their hospital stay was planned at the time of admission; 64 of these patients were classified into the early invasive group (<24h) and 96 were classified to the delayed invasive group (≥24h). We evaluated the primary outcome which was defined as a composite of cardiac mortality, life-threatening arrhythmia, and non-fatal myocardial infarction (MI). The median time between presentation and CAG was 2h in the early invasive group and 240h in the delayed group. During follow-up, the primary outcome was significantly lower in the early invasive group [hazard ratio (HR), 0.52; 95% confidence interval (CI), 0.30-0.87; p=0.01]. After the adjustment of confounding factors, the primary outcome was significantly less frequent (HR, 0.44; 95% CI, 0.23-0.78; p=0.004) in the early invasive group compared to the delayed invasive group. The early invasive strategy was associated with a lower risk of the composite primary outcome in the long-term follow-up of patients with NSTE-ACS and concomitant CHF.

Timing of coronary angiography in survivors of out-of-hospital cardiac arrest without obvious extracardiac causes

BackgroundIndications and timing of coronary angiography in patients surviving out-of-hospital cardiac arrest (OHCA) remain controversial. The aim of the present study was to assess the impact of an early invasive strategy in patients presenting with an OHCA and no obvious extracardiac cause. MethodsBetween January 1st 2009 and December 31st 2014 a total 612 survivors of OHCA were admitted to our institution. Patients with no obvious extracardiac cause (n=507) were stratified into two groups: patients that underwent cardiac catheterization ≤3h (early invasive; n=291) and patients not undergoing cardiac catheterization within 3h (non-early invasive; n=216). Primary endpoint was all-cause mortality at 30days. ResultsAll-cause 30-day mortality was 28.9% in the early invasive group vs. 36.6% in the non-early invasive group (log-rank p=0.071). After propensity analyses, an early invasive strategy, as compared to a non-early strategy, was not associated with 30-day mortality (adjusted Hazard ratio [HR] 0.69; 95% CI 0.35–1.37; p=0.029). Cox multivariable regression analyses demonstrated age (HR 1.04/year; 95% CI 1.02–1.07) and presentation with cardiogenic shock (HR 5.1; 95% CI 1.8–14.0) to be the sole independent predictors of 30-day mortality. ConclusionsIn this retrospective study, early coronary angiography (<3h), as compared to a non-early invasive strategy, was not associated with reduced 30-day mortality in patients hospitalized after OHCA, irrespective of the presence of ST segment elevation or cardiogenic shock at presentation.

Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials

A routine invasive strategy is recommended for patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, optimal timing of invasive strategy is less clearly defined. Individual clinical trials were underpowered to detect a mortality benefit; we therefore did a meta-analysis to assess the effect of timing on mortality. We identified randomised controlled trials comparing an early versus a delayed invasive strategy in patients presenting with NSTE-ACS by searching MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. We included trials that reported all-cause mortality at least 30 days after in-hospital randomisation and for which the trial investigators agreed to collaborate (ie, providing individual patient data or standardised tabulated data). We pooled hazard ratios (HRs) using random-effects models. This meta-analysis is registered at PROSPERO (CRD42015018988). We included eight trials (n=5324 patients) with a median follow-up of 180 days (IQR 180-360). Overall, there was no significant mortality reduction in the early invasive group compared with the delayed invasive group HR 0·81, 95% CI 0·64-1·03; p=0·0879). In pre-specified analyses of high-risk patients, we found lower mortality with an early invasive strategy in patients with elevated cardiac biomarkers at baseline (HR 0·761, 95% CI 0·581-0·996), diabetes (0·67, 0·45-0·99), a GRACE risk score more than 140 (0·70, 0·52-0·95), and aged 75 years older (0·65, 0·46-0·93), although tests for interaction were inconclusive. An early invasive strategy does not reduce mortality compared with a delayed invasive strategy in all patients with NSTE-ACS. However, an early invasive strategy might reduce mortality in high-risk patients. None.

Early Invasive Versus Selective Strategy for Non–ST-Segment Elevation Acute Coronary Syndrome: The ICTUS Trial

BackgroundThe ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes) trial compared early invasive strategy with a selective invasive strategy in patients with non–ST-segment elevation acute coronary syndrome (NSTE-ACS) and an elevated cardiac troponin T. No long-term benefit of an early invasive strategy was found at 1 and 5 years. ObjectivesThe aim of this study was to determine the 10-year clinical outcomes of an early invasive strategy versus a selective invasive strategy in patients with NSTE-ACS and an elevated cardiac troponin T. MethodsThe ICTUS trial was a multicenter, randomized controlled clinical trial that included 1,200 patients with NSTE-ACS and an elevated cardiac troponin T. Enrollment was from July 2001 to August 2003. We collected 10-year follow-up of death, myocardial infarction (MI), and revascularization through the Dutch population registry, patient phone calls, general practitioners, and hospital records. The primary outcome was the 10-year composite of death or spontaneous MI. Additional outcomes included the composite of death or MI, death, MI (spontaneous and procedure-related), and revascularization. ResultsTen-year death or spontaneous MI was not statistically different between the 2 groups (33.8% vs. 29.0%, hazard ratio [HR]: 1.12; 95% confidence interval [CI]: 0.97 to 1.46; p = 0.11). Revascularization occurred in 82.6% of the early invasive group and 60.5% in the selective invasive group. There were no differences in additional outcomes, except for a higher rate of death or MI in the early invasive group compared with the rates for the selective invasive group (37.6% vs. 30.5%; HR: 1.30; 95% CI: 1.07 to 1.58; p = 0.009), driven by a higher rate of procedure-related MI in the early invasive group (6.5% vs. 2.4%; HR: 2.82; 95% CI: 1.53 to 5.20; p = 0.001). ConclusionsIn patients with NSTE-ACS and elevated cardiac troponin T levels, an early invasive strategy has no benefit over a selective invasive strategy in reducing the 10-year composite outcome of death or spontaneous MI, and a selective invasive strategy may be a viable option in selected patients.

Very Early versus Early Invasive Strategy after Successful Thrombolysis in Patients with ST Segment Elevation Myocardial Infarction

Background: Till this time even with superiority of primary percutaneous coronary intervention (pPCI) in the management of ST segment elevation myocardial infarction (STEMI), most of patients present to hospitals without pPCI facilities receive fibrinolytic therapy. The current recommendations support routine early invasive strategy within 24 hours. Objectives: we aimed at evaluating the best timing of invasive strategy within the first 24 hours. Methods: The study was conducted on 60 STEMI patients who were referred to our center after successful thrombolysis. Patients were randomized into 2 groups: Very early invasive group (n=30): subjected to very early invasive strategy within 3 to 12 hours post thrombolysis. Early invasive group (n=30): subjected to early invasive strategy within 12 to 24 hours. The primary endpoints were the composite endpoints of major adverse cardiac events (MACEs). Secondary endpoints were achievement of TIMI III flow with MBG II or III. Safety endpoints were bleeding complications. Results: Both groups were homogenous regarding the demographic, clinical, and angiographic data before invasive strategy. TIMI III flow and MBG II or III were achieved in 83.3% of patients in the very early invasive group vs. 86.6% in the early group (P = 0.955). There was no difference between both groups regarding the composite endpoints MACEs (P= 0.667) or bleeding complications (P=0.528). Conclusion: The study did not demonstrate a correlation between magnitude of benefit and timing of early PCI post successful thrombolysis in patients with STEMI. Thus, early invasive strategy could be scheduled depending on the logistics of the reference catheterization laboratory within 24 hours post thrombolysis.

Dynamic Use of B-Type Natriuretic Peptide–Guided Acute Coronary Syndrome Therapy

BackgroundVery few studies have evaluated the potential of using B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) as surrogate markers to guide clinical interventional or conservative therapy decisions. AimThe aim of the current study was to evaluate the potential of using BNP and NT-proBNP as surrogate markers to guide clinical interventional or conservative therapy decisions. MethodsWe identified randomized controlled trials that randomized patients with acute coronary syndrome (ACs) of unstable angina and myocardial infarction without sT-segment elevation ACs to early invasive therapy versus a more conservative approach by systematic search of articles and databases. ResultsFive randomized controlled trials with a total of 8125 patients and with a mean duration of 11.2months were included in the meta-analysis. At a mean follow-up of 11.2months, the incidence of all-cause mortality was 5.9% in the early invasive group, compared with 6.8% in the conservative group (risk ratio = 0.74; 95% confidence interval, 0.59-0.86; P = 0.001). Conclusionsin summary, BNP/NT-proBNP-guided management of ACs is significantly improved by early invasive therapy by improving long-term survival and reducing nonfatal myocardial infarction for unstable angina. However, there does not seem to be a clear benefit of using such a strategy over existing clinical recommendations.

Early or Selective Invasive Strategy in Patients with Non-ST-segment Elevation Acute Coronary Syndrome According to the Risk Factors at Presentation? An Outcome Study

Aims: Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). History of diabetes mellitus (DM), chronic kidney disease (CKD) and elevated GRACE risk score are all factors defining a higher risk of MACE. We aimed to compare the outcome of patients with early vs selective invasive strategy according to the risk factors at presentation. Methodology: We enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), 52 (29.2%) had DM, 32 (19.7%)-CKD, defined when MDRD measured glomerular filtration rate (GFR) was <60ml/min/1.73m and 28 (15.7%) had GRACE≥140. The study had two arms: an early invasive strategy one (coronary arteriography and percutaneous coronary intervention within 24 hours after admission), Original Research Article Dimitrov et al.; CA, 2(4): 205-222, 2014; Article no. CA.2014.4.006 206 and a selective invasive strategy arm (medical stabilization, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). Follow-up was 22.8±14 months. Results: For the whole group MACE occurred less often and the event free period was longer in the early invasive strategy group compared to selective invasive one (p=0.001). Early invasive strategy in diabetic patients, those with CKD and with GRACE ≥140 was associated with a reduced MACE rate (p=0.008, 0.016 and 0.006, respectively) and longer time to MACE occurrence compared with the selective invasive strategy. When we evaluated separately non-diabetics, patients with normal renal function and those with GRACE <140 we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. Early invasive strategy, however, showed some advantage over the selective one also in the subgroup analysis-the time to occurrence of MACE was prolonged in patients with lower risk at presentation. Conclusions: Early invasive strategy in UA/NSTEMI is associated with a reduced MACE rate and longer event-free period compared with selective invasive strategy. This benefit is clearly evident in higher risk subsets (patients with DM, CKD and GRACE ≥140).

Early Invasive Versus Initial Conservative Treatment Strategies in Octogenarians with UA/NSTEMI

BackgroundPrevious studies have demonstrated improved outcomes with an early invasive strategy in patients with unstable angina/non-ST-elevation myocardial infarction (UA/NSTEMI). However, there are limited data for patients ≥80 years of age in these studies. MethodsWe used the 2003-2010 Nationwide Inpatient Sample databases to identify all patients ≥80 years of age (octogenarians) with UA/NSTEMI. Multivariable logistic regression was used to compare in-hospital outcomes in octogenarians with UA/NSTEMI undergoing early invasive (coronary angiography within 48 hours of admission, with or without revascularization) versus initial conservative treatment. ResultsAmong 968,542 octogenarians with UA/NSTEMI, 806,902 (83.3%) were managed using an initial conservative approach and 161,640 (16.7%) using an early invasive strategy. Patients in the early invasive group were more likely to be younger, men, white, and had a higher prevalence of smoking, dyslipidemia, obesity, hypertension, known coronary artery disease, carotid artery disease, and peripheral vascular disease. In-hospital mortality was significantly lower in octogenarians in the early invasive group (adjusted odds ratio [OR] 0.76; 95% confidence interval [CI], 0.74-0.78). Early invasive strategy was associated with lower rates of acute ischemic stroke (adjusted OR 0.63; 95% CI, 0.60-0.66), intracranial hemorrhage (adjusted OR 0.60; 95% CI, 0.510.70), gastrointestinal bleeding (adjusted OR 0.63; 95% CI, 0.60-0.65), and shorter average length of stay (5.3 vs 5.8 days, P <.001), but higher cardiogenic shock (adjusted OR 2.14; 95% CI, 2.06-2.23) and total hospital cost (23,584 vs 13,278 USD). ConclusionCompared with an initial conservative approach, an early invasive strategy in octogenarians with UA/NSTEMI was associated with lower in-hospital mortality, acute ischemic stroke, intracranial hemorrhage, gastrointestinal bleeding, and shorter length of stay, but higher cardiogenic shock and total hospital cost.

Invasive versus conservative strategies in patients with non-st-elevation acute coronary syndrome: an updated meta-analysis

Background: Early invasive approach is recommended for non-ST-segment elevation acute coronary syndromes (NSTE-ACS). However, recent guidelines propose early or deferred angiography within the routine invasive strategy. We sought to perform an updated meta-analysis to determine whether early invasive therapy improves clinical outcomes in patients with NSTE-ACS. Methods: Randomized controlled trials (RCTs) identified through search of MEDLINE, EMBASE, and the Cochrane databases (1991 through December 2012) and hand searching of cross references from original articles and reviews. Clinical trials that randomized NSTE-ACS patients to early invasive versus delayed invasive or more conservative approach were included for analysis. Major outcomes of death and myocardial infarction (MI) occurring from index hospitalization to the end of follow-up were extracted from published results of eligible studies. Secondary end points included the composite of death or MI; rehospitalization; recurrent angina; and repeat revascularization. The pooled effects were calculated using fixed-effects model (Mantel-Haenszel method) or random effects models (Dersimonian and Laird method). Results: A total of fifteen RCTs including 15,315 patients were included in this meta-analysis. No statistically significant differences in the risk of death (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.70–1.06, p=0.15) or MI (OR 0.92, 95% CI 0.74–1.13, p=0.41) were detected between early invasive group versus delayed invasive or conservative approach group. Early invasive strategy significantly reduced the risk of composite of death or MI (OR 0.82, 95% CI 0.70–0.96, p=0.02), rehospitalization (OR 0.80, 95% CI 0.72–0.89, p<0.001), and recurrent angina (OR 0.75, 95% CI 0.56–0.99, p=0.04). Stratified analysis by the invasiveness suggested similar odds of mortality in studies comparing invasive versus conservative strategy (OR 0.87, 95% CI 0.68–1.11, p=0.25) and early versus late invasive approach (OR 0.81, 95% CI 0.50–1.32, p=0.41). Conclusions: Management of NSTE-ACS by early invasive strategy does not decrease the risk of death or MI at long-term follow up. However, early intervention reduces the risk of recurrent angina and rehospitalization compared with delayed intervention or conservative management.

Timing of Invasive Strategy in Diabetic and Non-Diabetic Patients with Non-St-Segment Elevation Acute Coronary Syndrome

Patients with acute coronary syndrome without ST segment elevation are a heterogeneous group with respect to the risk of having a major adverse cardiac event (MACE). A history of diabetes mellitus (DM) is no doubt one of the factors that define a patient as being at a higher risk of having the syndrome. To compare early invasive strategy with selective invasive strategy indicated for patients with and without DM. The study enrolled 178 patients with unstable angina or non-ST elevation myocardial infarction (UA/NSTEMI), and of these 52 (29.2%) had DM. Patients were randomly assigned to an early invasive strategy (these were scheduled to undergo coronary arteriography and percutaneous coronary intervention within 24 hours after admission) or to a selective invasive strategy (at first these were medically stabilized, with coronary arteriography required only in case of angina recurrence and/or evidence of inducible myocardial ischemia). The patients were followed up for a mean period of 22.8 +/- 14 months. In the follow up the diabetics allocated to an early invasive strategy were found to have a significantly lower angina recurrence incidence (p = 0.005), rehospitalization rate (p = 0.001), fewer arteriographies (p = 0.001) and coronary interventions (p = 0.001) and low cumulative incidence of MACE (p = 0.008) in comparison with the diabetics assigned to selective invasive strategy. We also found, using the Kaplan-Meier curves survival analysis, that the time to MACE in patients assigned to an early invasive strategy was significantly longer than that in the group of selective invasive strategy. In the follow-up of non-diabetics we found no significant difference in MACE rate between the patients allocated to early invasive strategy and those assigned to selective invasive strategy. In the selective invasive strategy group, however, the cardiovascular adverse events tended to occur earlier than in the early invasive strategy group. Early invasive strategy in diabetic patients with non-ST-segment elevation acute coronary syndrome is associated with a reduced MACE rate compared with the selective invasive strategy used in these patients. Early invasive strategy applied in diabetic patients is also associated with a significantly longer time to MACE. In non-diabetics the advantages of early over selective invasive strategy are not so clearly differentiated.

Influence of the Timing of Percutaneous Coronary Intervention on Clinical Outcomes in Non-ST-Elevation Myocardial Infarction

Background and ObjectivesWe have intended to investigate the influence of the timing of invasive procedures on all-cause mortality, recurrent myocardial infarction (MI), re-hospitalization due to cardiac causes and left ventricular function over a 3-month period among patients with Non-ST-elevation myocardial infarction (NSTEMI).Subjects and MethodsA total of 131 NSTEMI patients with moderate-high Thrombolysis in Myocardial Infarction risk scores, who had been admitted to our department between July 2011-December 2011 were included in our study. They had been randomized into 2 groups according to the timing of the percutaneous coronary intervention (PCI). Patient undergoing PCI in the first 24 hours of hospitalization were named the "Early Invasive Group" and those undergoing PCI between 24-72 hours of hospitalization were named the "Delayed Invasive Group". All patients were followed up for 3 months.ResultsThird month left ventricular ejection fraction (LVEF) values were higher in the early invasive group (59.9±6.0% vs. 54.1±8.7%; p<0.001). Recurrent MI rates were lower in the early invasive group (2.9% vs. 14.5%; p=0.016). Similarly, hospitalization rates due to cardiac events were lower in the early invasive group (8.7% vs. 30.6%; p=0.001). All cause mortality appeared to be lower in the early invasive group, although not to a statistically significant degree (0% vs. 4.8%; p=0.065).ConclusionThe early invasive strategy appears to be more effective for the reduction of recurrent MI, re-hospitalization due to cardiac events, and the preservation of 3rd month LVEF in patients with moderate-high risk NSTEMI when compared to a delayed invasive strategy.