Early Invasive Strategy In Patients Research Articles

Relationship of Frontal QRS-T Angle with Coronary Flow Grade and Adverse Events Before Percutaneous Coronary Intervention in Patients with Non-ST-Elevation Myocardial Infarction.

Electrocardiography is used in the initial risk assessment of patients with non-ST-elevation myocardial infarction. The frontal QRS-T angle is an electrocardiography parameter that may be affected by the alterations in the coronary blood flow. This study aimed to explore the relationship of the frontal QRS-T angle with coronary flow grade and adverse events in non-ST-elevation myocardial infarction patients. A total of 191 non-ST-elevation myocardial infarction patients were divided into 2 groups based on the thrombolysis in myocardial infarction (TIMI) flow level on coronary angiography before revascularization, namely TIMI 0/1 and TIMI 2/3. The frontal QRS-T angle obtained before revascularization was compared between the groups and its relationship with adverse events was examined. In-hospital all-cause mortality, repeat target lesion revascular-ization, new-onset heart failure, ventricular arrhythmias, and atrial fibrillation were defined as adverse events. Frontal QRS-T angle was wider in the patients with TIMI 0/1 flow compared to the patients with TIMI 2/3 flow (P < 0.001). The frontal QRS-T angle was determined to be a predictor of TIMI flow grade 0/1 before revascularization in patients with non-ST-elevation myocardial infarction (odds ratio: 1.51; 95% CI: 1.30-1.75; P < 0.001). The frontal QRS-T angle was a predictor of the adverse events during hospitalization in the patients with non-ST-elevation myocardial infarction (odds ratio: 1.11; 95% CI: 1.04-1.19; P = 0.002). The cut-off values of the frontal QRS-T angle for TIMI flow grade and adverse events were determined to be 73.5°, based on receiver operating characteristic curve analysis. Increased frontal QRS-T angle may be a useful electrocardiography parameter for determining TIMI flow grade and the need for an early invasive strategy in patients with non-ST-elevation myocardial infarction.

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.

Prognostic benefit from an early invasive strategy in patients with non ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

Abstract Objectives The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. Methods This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (&amp;lt;24 h) in patients with: (a) GRACE risk score &amp;gt;140 and (b) patients with “established NSTEMI” (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score &amp;lt;140. Results From 2003 to 2017, 6454 patients with “new high-risk NSTEACS” were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary interven- tion in patients with NSTEACS and GRACE &amp;gt;140 [HR 0.62 (IC 95% 0.57–0.67), HR 0.62 (IC 95% 0.56–0.68), HR 0.57 (IC 95% 0.53–0.61), respectively]. In patients with NSTEACS and GRACE &amp;lt;140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56–0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78–1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75–1.24)]. Conclusions An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score &amp;lt;140 with established NSTEMI or ST/T-segment changes. Funding Acknowledgement Type of funding sources: None.

Management and outcome of non-ST-elevation acute coronary syndromes in the elderly admitted to spoke hospitals with no cath-lab facility

Abstract Background Current guidelines recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the role of an invasive strategy in elderly patients remains controversial and may be difficult to achieve in spoke hospitals with no cath-lab facility. Purpose We aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals. Methods Observational retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals, where a service strategy (same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography) was available. Results From 2013 to 2017, 639 patients were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network; of these, 181 (28%) were ≥80 years (median 84, IQR 82–89). In the elderly conservative strategy was chosen in 76 patients (42%). When the invasive strategy was chosen, 104 patients (93%) were managed with a Service strategy with no major adverse event observed during the back transfer from the invasive center to the referring spoke center, whereas the rest of the patients (8, 7%) were transferred from the spoke hospital to the hub center and completed their hospital stay without returning to the spoke center. Of patients initially managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 11 (10%) and the patients remained in the hub center. The median time to access to cath-lab was 50 hours (IQR 25–87), with 73 patients (70%) reaching the invasive procedure &amp;lt;72 h from the hospital admission and 23 (22%) &amp;lt;24 h. Conservative strategy was associated with older age, known previous CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD, and atrial fibrillation (all p&amp;lt;0.03; Table). At 1-year follow-up, the overall survival was significantly higher in patients treated with invasive strategy compared to patients managed conservatively (94%±2 vs. 54%±6, p&amp;lt;0.001; HR: 10.4 [4.7–27.5] p&amp;lt;0.001; Figure), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0–4.0]; p&amp;lt;0.001). Conclusion An invasive strategy may confer a survival benefits in the elderly with NSTE-ACS. When the invasive strategy is chosen, the same-day transfer between spoke hospital and hub center with the cath-lab facility (service strategy) is safe and granted the access to cath-lab in a timely fashion even in the elderly. Funding Acknowledgement Type of funding sources: None. Table 1Figure 1

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.

Importance of Risk Assessment in Timing of Invasive Coronary Evaluation and Treatment of Patients With Non–ST‐Segment–Elevation Acute Coronary Syndrome: Insights From the VERDICT Trial

BackgroundThe optimal timing of invasive examination and treatment of high‐risk patients with non–ST‐segment–elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard‐care invasive coronary angiography on the risk of all‐cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial.Methods and ResultsPatients with clinical suspicion of non–ST‐segment–elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48–72 hours) invasive strategy. The primary outcome of the present study was all‐cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow‐up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16–3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63–1.10]) (P interaction=0.006).ConclusionsIn patients with non–ST‐segment–elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high‐risk and low‐risk patients with non–ST‐segment–elevation acute coronary syndrome.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT02061891.

Prognostic benefit from an early invasive strategy in patients with non-ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines.

The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (< 24h) in patients with: (a) GRACE risk score > 140 and (b) patients with "established NSTEMI" (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score < 140. From 2003 to 2017, 6454 patients with "new high-risk NSTEACS" were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary intervention in patients with NSTEACS and GRACE > 140 [HR 0.62 (IC 95% 0.57-0.67), HR 0.62 (IC 95% 0.56-0.68), HR 0.57 (IC 95% 0.53-0.61), respectively]. In patients with NSTEACS and GRACE < 140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56-0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78-1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75-1.24)]. An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score < 140 with established NSTEMI or ST/T-segment changes.

Frontal QRS-T angle predicts syntax score in patients with non-ST elevation myocardial infarction

BackgroundEarly risk stratification based on SYNTAX score plays a crucial role to identify the need for early invasive strategy in patients with NSTEMI. The predictive role of frontal QRS-T angle [f(QRS-T)] on the atherosclerotic burden of CAD is less clear in NSTEMI patients. In this study, we aimed to investigate the relationship between f(QRS-T) and SYNTAX score in NSTEMI patients. MethodsA total of consecutive 269 patients with the diagnosis of NSTEMI transferred to coronary care unit were included in the study. f(QRS-T) was calculated as the absolute value of the difference between the frontal plane QRS and T axes based on automatic report of ECG machine. Syntax score was computed using an online SYNTAX score calculator by well-experienced two cardiologists blinded to the study data. The study population was divided into two groups based on the SYNTAX score low SYNTAX score (≤23), and high SYNTAX score (>23). ResultsLeft ventricle ejection fraction (LVEF) (p = 0.001), hemoglobin (p = 0.03) and HDL-C (p = 0.04) levels were lower in the intermediate-high SYNTAX group. Age (72.1 ± 12.5 vs. 64.6 ± 9.4 respectively; p < 0.001), LAD as infarct-related artery 30 (%65.2) vs. 50 (%29.1) respectively; (p = 0.001), f(QRS-T) (100.5 ± 55.3 vs. 65.1 ± 53.1 respectively p = 0.006), troponin I peak (p = 0.06) were higher among patients with intermediate-high Syntax score. In receiver-operating characteristic (ROC) curve analysis, the value for f(QRS-T) to detect syntax score ≥ 23 with a sensitivity of 77% and specificity of 63% was 73,5° in NSTEMI patients(AUC = 0.69). Univariate logistic regression analysis identified that age, LVEF, HDL-C, hemoglobin, infarct-related artery, f(QRS-T) were significantly associated with SYNTAX score. Multivariate logistic regression analysis showed that age (OR: 1.135, 95% CI: 1.039–1.153, p = 0.045), infarct related artery-LAD (OR: 2.897, 95% CI: 1.023–8.209, p = 0.001) and f(QRS-T) (OR: 3.587, 95% CI: 1.093–11.772, p = 0.001) were the independent predictors of SYNTAX score. ConclusionIn NSTEMI patients, f(QRS-T) has been found to be a useful decision-making tool to predict SYNTAX score to assess early invasive strategy.

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)

Indications for an early invasive strategy in NSTE-ACS patients.

An early invasive strategy in patients who have acute coronary syndrome without ST-elevation (NSTE-ACS) can improve clinical outcome in high-risk subgroups. According to the current guidelines of the European Society of Cardiology (ESC), the majority of NSTE-ACS patients are classified as “high-risk”. We propose to prioritise patients with a global registry of acute coronary events (GRACE) risk score >140 over patients with isolated troponin rise or electrocardiographic changes and a GRACE risk score <140. We also acknowledge that same-day transfer for all patients at a high risk is not necessary in the Netherlands since the majority of Dutch cardiology departments are equipped with a catheterisation laboratory where diagnostic coronary angiography is routinely performed in NSTE-ACS patients. Therefore, same-day transfer should be restricted to true high-risk patients (in addition to those NSTE-ACS patients with very high-risk (VHR) criteria) in centres without coronary angiography capabilities.

Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units

ObjectiveCurrent guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU). DesignA prospective cohort study was carried out. SettingThe ICCUs of 8 hospitals in Catalonia (Spain). PatientsConsecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria. InterventionsEIS was defined as the performance of coronary angiography within the first 6 h in patients at very high-risk or within 24 h in high-risk patients. Outcome variablesMortality or readmission at 6 months. ResultsA total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: 0.66, 95% confidence interval 0.45–0.97; p = 0.035). ConclusionsThe EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.

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.

Early Invasive Strategy in Patients over 75 Years with Acute Coronary Syndrome. A Single Center Study

to assess the clinical status, comorbidities, complications, in-hospital mortality and its structure in dependence of age and type of acute coronary syndrome (ACS) in case of early invasive strategy of ACS management. we included in this retrospective study data of all patients (n=1353) with ACS subjected to emergency and urgent myocardial revascularization in High Medical Technologies Center (Kaliningrad, Russia) in 2014-2016. Age of 984 patients was &lt;75 (group 1) and of 369 &gt;75 years (group 2). Mean age was 60±8.6 and 80.1±4.2 years, in groups 1 and 2, respectively. Anamnesis of group 2 patients was substantially burdened by myocardial infarction and stroke, they significantly more often had reduced left ventricular ejection fraction (EF), congestive heart failure, valve disorders, and atrial fibrillation. Patients of group 2 more frequently had severe manifestations of acute heart failure (AHF) and cardiogenic shock. Portions of patients with Killip class III were 5.9 and 11.4%, IV -2.1% and 9.1% in 1 and 2, respectively. Group 2 patients compared with those of group 1 had higher GRACE score and higher bleeding risk. In-hospital all-cause mortality was 3.1 and 10%, ST elevation myocardial infarction mortality - 2.6 and 9.5% in groups 1 and 2, respectively. Non-ST elevation myocardial infarction + unstable angina mortality (0.5%) did not differ between groups. Mortality from AHF (2 and 6.5%) and percutaneous coronary intervention complications (stent thrombosis and no-reflow) (0.5 and 2.4%) was significantly higher in group 2. AHF mortality was similar in patients with preserved and mid-range EF of both groups, but among those with reduced EF it was significantly higher in group 2 compared with group 1 (7.3 vs. 18.6%, respectively). There were no significant differences between groups in rates of gastro-intestinal and major bleedings. Clinical course of ACS was more severe in patients aged &gt;75 years compared with patients aged &lt;75 years. Early invasive strategy was effective irrespective of patient's age and ACS type. Rate of fatal outcomes due to complications of stenting and AHF were higher among very elderly patients. AHF more often caused death in very elderly patients with reduced EF. The rest of the structure of complications and mortality was similar in patients of different ages.

Invasive strategy and frailty in very elderly patients with acute coronary syndromes.

Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients. The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-hazard ratio [sHR] 2.32, 95% confidence interval [CI]: 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI: 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI: 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032). An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

Long-term Follow-up of the Trial of Routine Angioplasty and Stenting After Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI)

BackgroundThe Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) demonstrated superiority of routine early coronary angiography (and percutaneous coronary intervention [PCI]) compared with standard therapy in fibrinolytic-treated patients with ST-segment elevation myocardial infarction (STEMI) at 30 days. The aim of the current study was to evaluate the long-term (>7 year) effects of an early invasive strategy. MethodsWe linked the study cohort and administrative datasets to assess long-term follow-up status including repeat procedures, hospitalizations, and major adverse cardiovascular events (MACE). Kaplan-Meier and Cox regression analysis were used to evaluate the relationship between randomized treatment and long-term adverse outcomes. ResultsA total of 881 patients had long-term follow-up and were included in our study. After a mean follow-up of 7.8 years, there were no significant differences in death, myocardial infarction (MI), unstable angina, stroke, transient ischemic attack (TIA), or heart failure admissions (hazard ratio [HR] 0.91; 95% confidence interval [CI] 0.73–1.13]; P = 0.41) between those randomized to an early invasive vs standard treatment strategy. Following the index hospitalization, there were no significant difference in the rates of coronary revascularization between the early invasive and the standard therapy groups (81 [19.3%] vs 76 [17.9%]; P = 0.61). ConclusionsDespite the short-term benefit and safety of an early invasive strategy in patients with STEMI receiving fibrinolysis, no statistically significant differences in MACE were observed over 7.8 years.

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.

Contemporary practice and outcomes of an elderly cohort of Japanese patients with non-ST-elevation acute coronary syndrome in the era of routine early invasive strategy

BackgroundAn early invasive strategy for patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) has been recommended. However, patients at greater risk including the elderly are more often managed conservatively. We aimed to elucidate contemporary practice and outcomes of patients with NSTE-ACS who were referred to our hospital located in Kitakyushu City, one of the most aging metropolises in Japan. MethodsA total of 270 consecutive NSTE-ACS patients hospitalized between January 2012 and December 2014 were retrospectively studied. ResultsMedian [interquartile range] age was 73 [64, 80]years. Coronary angiography was performed in 264 (98%) patients. Importantly, 75% and 89% underwent angiography within 24h and 72h after admission, respectively. Revascularization was done in 124 (79%). The all-cause, in-hospital mortality was 3.7% and was higher in patients aged ≥80years (8.5% vs. 2.0% in those aged <80years, p<0.0001). No patient developed major bleeding or stroke during hospitalization. Killip class IV at presentation (odds ratio [OR] 8.77, 95% confidence intervals [CI] 1.64–47.6) and left main trunk disease (OR 7.58, 95% CI 1.28–45.5) were independently associated with in-hospital death. These two variables and a high (≥140) GRACE score were associated with a higher 1-year mortality by Kaplan-Meier survival analysis (p<0.0001). ConclusionsAn early invasive strategy was safely done in an elderly cohort of Japanese patients with NSTE-ACS. In addition to early invasive approach, a further therapeutic strategy, most probably targeting a shock status, is needed to improve both short- and long-term survival.

Underuse of an invasive strategy for patients with diabetes with acute coronary syndrome: a nationwide study

BackgroundGuidelines recommend an early invasive strategy for patients with diabetes with acute coronary syndromes (ACS). We investigated if patients with diabetes with ACS are offered coronary angiography (CAG) and revascularisation...

Efficacy and Safety of a Routine Early Invasive Strategy in Relation to Time from Symptom Onset to Fibrinolysis (a Subgroup Analysis of TRANSFER-AMI)

The aim of this study was to assess the efficacy and safety of an early invasive strategy post-fibrinolysis in relation to time from symptom onset to fibrinolysis in patients with ST-elevation myocardial infarction (STEMI). The Trial of Routine Angioplasty and Stenting after Fibrinolysis to Enhance Reperfusion in Acute Myocardial Infarction (TRANSFER-AMI) randomized 1,059 patients receiving fibrinolysis for STEMI to an early invasive strategy versus standard therapy. The primary end point was the composite of death, reinfarction, recurrent ischemia, new or worsening heart failure, or cardiogenic shock at 30 days. In this post hoc subgroup analysis, we examined the effect of an early invasive strategy on efficacy and safety outcomes after stratification by time from symptom onset to fibrinolysis (<2 or ≥2 hours). Of 1,059 patients in TRANSFER-AMI, 557 (53%) received fibrinolysis <2 hours and 502 (47%) ≥2 hours after symptom onset. Compared to patients who received fibrinolysis within 2 hours of symptoms, patients who received fibrinolysis ≥2 hours after symptom onset had higher Global Registry of Acute Coronary Events risk scores (median 127 vs 122, p = 0.004). The effect of an early invasive strategy did not differ between symptom-to-fibrinolysis time strata for the primary efficacy end point (p-heterogeneity = 0.67), 30-day mortality, the composite of death or reinfarction at 30 days, 6 months, or 1 year, or bleeding (all p-heterogeneity >0.40). In conclusion, the efficacy and safety of an early invasive strategy in patients undergoing fibrinolysis for STEMI do not vary in relation to time (<2 or ≥2 hours) from symptom onset to fibrinolysis.