Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients

Milosević, A; Vasiljevic-Pokrajcic, Zorana; Milašinović, Dejan; Marinković, Jelena; Vukčević, Vladan; Stefanović, Branislav; Ašanin, Milika; Dikic, Miodrag; Stankovic, S.; Stanković, Goran

doi:10.1016/j.jcin.2015.11.018

Cited by 132 publications

(91 citation statements)

References 25 publications

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“…[7] The recently published RIDDLE-NSTEMI study showed an improved outcome for those non-ST-elevation AMI patients that underwent coronary intervention within 2 hours after admission. [2] These results underline the importance of early decision-making in patients with suspected AMI and support the development of rapid rule-in protocols. The first 1-hour approach using hs-TnI sampling has been investigated in the APACE cohort, which is now incorporated in the 2015 ESC guideline.…”

Section: Discussionmentioning

confidence: 64%

“…[1,2] Patients with acute onset chest pain frequently present to the ED, while only 15–20% of all patients actually have acute myocardial injury. [3] Earlier studies showed, that an early invasive approach is able to improve outcome in AMI patients.…”

Section: Introductionmentioning

confidence: 99%

“…[3] Earlier studies showed, that an early invasive approach is able to improve outcome in AMI patients. [1,2] On the other hand, invasive therapy itself is associated with higher costs and possible complications. [4–6] This makes the accurate identification of AMI patients crucial.…”

Section: Introductionmentioning

confidence: 99%

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Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Neumann¹,

Sörensen²,

Ojeda³

et al. 2017

PLoS ONE

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ObjectiveThere is a clinical need for early and accurate diagnosis of acute myocardial infarction (AMI). Current European Society of Cardiology (ESC) guidelines recommend diagnosis of non-ST-elevation AMI based on serial troponin measurements. We aimed to challenge the ESC guidelines using 1) a high-sensitivity troponin I (hs-TnI) baseline cutoff, 2) an absolute hs-TnI change after 1 hour and 3) additional application of an ischemic ECG.Methods1,516 patients with suspected AMI presenting to the emergency department were included. Hs-TnI was measured directly at admission, after 1 and 3 hours. We investigated baseline concentrations, absolute changes of hs-TnI and additional application of an ischemic ECG to diagnose AMI. A positive predictive value (PPV) of more than 85% was targeted.ResultsThe median age of the study population was 65 years; 291 patients were diagnosed with AMI. The PPV of the 3-hours ESC algorithm was 85.5% (CI 79.7, 90.1) and 65.8% (CI 60.5,70.8) for the 1-hour algorithm. Using a high baseline hs-TnI concentration of 150 ng/L resulted in a PPV of 87.8% (CI 80.9,92.9). Alternatively, a hs-TnI change of 20 ng/L after 1 hour, resulted in a PPV of 86.5% (80.9,91.0), respectively for the diagnosis of AMI. Additional use of an ischemic ECG increased the PPV to 90.5% (CI 83.2,95.3), while reducing the efficacy.ConclusionThe diagnosis of AMI based on hs-TnI is challenging. The application of absolute hs-TnI changes after 1 hour may facilitate rapid rule-in of patients.Trial registrationwww.clinicaltrials.gov (NCT02355457).

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Section: Discussionmentioning

confidence: 64%

Section: Introductionmentioning

confidence: 99%

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Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Neumann¹,

Sörensen²,

Ojeda³

et al. 2017

PLoS ONE

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“…A number of randomized trials18, 19 showed that early or immediate PCI reduced the event rates in high‐risk patients. Given the absence of robust data on the pretreatment strategy and the fact that the interval between admission and PCI has now shortened with modern practice, our study supports the concept of synergistic antiplatelet therapy with ticagrelor and eptifibatide bolus in high‐risk patients with NSTE‐ACS patients undergoing early PCI.…”

Section: Discussionmentioning

confidence: 99%

Ticagrelor and Eptifibatide Bolus Versus Ticagrelor and Eptifibatide Bolus With 2‐Hour Infusion in High‐Risk Acute Coronary Syndromes Patients Undergoing Early Percutaneous Coronary Intervention

Marian

Alli

Solaiman

et al. 2017

JAHA

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BackgroundIn patients with non‐ST‐segment elevation acute coronary syndromes, inhibition of platelet aggregation (IPA) with a potent P2Y12 inhibitor, ticagrelor, was inferior to tirofiban infusion at 2 hours, indicating that glycoprotein IIb/IIIa inhibitors are still needed. Ticagrelor and eptifibatide bolus only may maximally inhibit platelet aggregation and decrease bleeding, but IPA with ticagrelor and eptifibatide bolus versus 2‐hour infusion is unknown.Methods and ResultsA total of 70 P2Y12‐naïve patients, with high‐risk non‐ST‐segment elevation acute coronary syndromes, were randomized to ticagrelor and eptifibatide bolus (group 1) versus ticagrelor and eptifibatide bolus with 2‐hour infusion (group 2). Levels of IPA with ADP, thrombin receptor‐activating peptide, collagen, and high on‐treatment platelet reactivity were measured by light transmission aggregometry at baseline and at 2, 6, and 24 hours after percutaneous coronary intervention in both groups. The primary end point, IPA with ADP 20 μmol/L at 2 hours, was 99.59±0.43% in group 1 versus 99.88±1.0% in group 2 (P<0.001 for noninferiority). High on‐treatment platelet reactivity with ADP was zero at 2, 6, and 24 hours in both groups. IPA levels with ADP, thrombin receptor‐activating peptide, and collagen were significantly higher at 2 and 6 hours than at 24 hours in both groups. Periprocedural myocardial infarction was not significantly different between the groups. Hemoglobin level was significantly less at 24 hours versus baseline in group 2 (13.35±1.8 versus 12.38±1.8 g/dL, respectively; P<0.01).ConclusionsTicagrelor and eptifibatide bolus maximally inhibited platelet aggregation at 2 hours, which was associated with no significant hemoglobin drop after percutaneous coronary intervention. This obviates the need for eptifibatide 2‐hour infusion and might decrease bleeding complications.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01919723.

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“…Conversely, a delayed strategy may yield benefits through plaque passivation by optimal medical treatment followed by intervention on more stabilized ("cooled") plaques; this potential advantage, however, may be counterbalanced by a higher risk for events while waiting for angiography. Currently there are ten randomized controlled trials (RCTs) that have compared early versus delayed intervention in NSTE-ACS patients with a large variation in timing, ranging from immediate up to 24 hours in the early group (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). Temporal differences of revascularization were even more pronounced in the delayed groups.…”

mentioning

confidence: 99%

Prime time for the sweet spot in timing of coronary invasive approach in patients with non-ST elevation myocardial infarction

Navarese¹,

Wernly

Lichtenauer

et al. 2018

J. Thorac. Dis.

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Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients

Cited by 132 publications

References 25 publications

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Early diagnosis of acute myocardial infarction using high-sensitivity troponin I

Ticagrelor and Eptifibatide Bolus Versus Ticagrelor and Eptifibatide Bolus With 2‐Hour Infusion in High‐Risk Acute Coronary Syndromes Patients Undergoing Early Percutaneous Coronary Intervention

Prime time for the sweet spot in timing of coronary invasive approach in patients with non-ST elevation myocardial infarction

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