Meta‐analysis of optimal timing of coronary intervention in non‐ST‐elevation acute coronary syndrome

Barbarawi, Mahmoud; Kheiri, Babikir; Zayed, Yazan; Barbarawi, Owais; Chahine, Adam; Haykal, Tarek; Kanugula, Ashok Kumar; Bachuwa, Ghassan; Alkotob, Mohammad Luay; Bhatt, Deepak L.

doi:10.1002/ccd.28280

Cited by 15 publications

(6 citation statements)

References 21 publications

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“…Adherence to guidelines in term of decision and timing of intervention in NSTE-ACS play a key role in improving patients’ outcomes, as the highest benefit was reported in high risk patients who were treated invasively in form of absolute risk reduction in addition to decrease recurrent ischemia, subsequent rehospitalization and revascularization as well as cardiovascular death and all-cause mortality at 30-days, 12 months and 5-years follow-up [ 15 , 24 ]. Recent Meta-analysis [ 25 ] provides strong evidence regarding the highest benefit of early invasive strategy in higher risk NSTE-ACS in term of lower major adverse cardiac events and recurrent ischemic events in parallel to what was reported by VERDICT trial [ 26 ]. However, we did not observe significant differences in in-hospital outcomes according to use of invasive strategy and this can be explained by the delayed catheterization if done in high-risk patients which can partially waive its benefit or catheterizing low risk-patients who usually benefit less from intervention compared to the higher risk categories.…”

Section: Discussionmentioning

confidence: 87%

Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq

Dakhil

Farhan

2021

BMC Health Serv Res

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Background Risk stratification is the cornerstone in managing patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS) and can attenuate the unjustified variability in treatment and guide the intervention decision notwithstanding its impact on better healthcare resources use. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice. Methods Multicentre prospective study recruited NSTE-ACS patients. Baseline characteristics were collected, TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores were calculated, management strategy as well as timing to intervention were recorded. Results n. = 150, 72% of them were males, mean age was (59 ± 12.32) years. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. Invasive strategy was adopted in 85.24 and 82.7% of low GRACE and TIMI risk categories respectively, while invasive approach used in 42.85 and 40% of high GRACE and TIMI risk categories respectively. The immediate intervention in less than 2 hours was more to be used in low-risk categories while the high-risk and very high-risk patients whom were managed invasively were catheterized within >72 h; or more frequently to be non-catheterized at all. Sixty percent of those with acute heart failure, 80.76% of those with ongoing chest pain, 85% of those with dynamic ST changes same as 80% of those with cardiogenic shock were treated conservatively. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach. Conclusions There is striking underuse of risk scores in practice that can contribute to treatment-risk paradox in managing NSTE-ACS in form of depriving those with higher risk from invasive strategy despite being the most beneficiaries. The paradox did not only involve the very high-risk patients but also the very high-risk criteria like ongoing chest pain and cardiogenic shock predicted conservative approach, this highlights that the entire approach to patients with NSTE-ACS should be reconsidered, regardless of the use of risk scores in clinical practice. Audit programs activation in middle eastern countries can inform policymakers to put a limit to the treatment-risk paradox for better cardiovascular care and outcomes.

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Section: Discussionmentioning

confidence: 87%

Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq

Dakhil

Farhan

2021

BMC Health Serv Res

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“…Similarly, there was no difference in terms of mortality (4.0% vs. 4.7%; OR: 0.85; 95% CI: 0.67–1.09; P = 0.20) or MI (6.7% vs. 7.7%; OR: 0.88; 95% CI: 0.53–1.45; P = 0.62) ( 17 ). However, another meta-analysis including 14 RCTs (9,637 patients) showed that the early invasive strategy was associated with a lower incidence of MACEs than the delayed invasive strategy (RR: 0.65; 95% CI: 0.49, 0.87; P = 0.003) ( 18 ). Contradictory results were obtained from our and previous studies.…”

Section: Discussionmentioning

confidence: 99%

Timing of angiography and outcomes in patients with non-ST-segment elevation myocardial infarction: Insights from the evaluation and management of patients with acute chest pain in China registry

Han

Sun

Qiao

et al. 2022

Front. Cardiovasc. Med.

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ObjectiveAlthough an invasive strategy has been recommended within 24 h for patients with non-ST-segment elevation myocardial infarction (NSTEMI), the optimal timing of the invasive strategy remains controversial. We sought to investigate the association between the different timings of invasive strategies and clinical outcomes in patients with NSTEMI.Materials and methodsPatients admitted with NSTEMI from the Evaluation and Management of Patients with Acute ChesT pain in China (EMPACT) registry between January 2016 and September 2017 were included. The primary outcomes were major adverse cardiac events (MACEs) within 30 days. Multivariable logistic regression was performed to assess independent risk factors for MACEs.ResultsA total of 969 patients with NSTEMI from the EMPACT Registry were eligible for this study. Coronary angiography (CAG) was performed in 501 patients [<24 h, n = 150 (15.5%); ≥ 24 h, n = 351 (36.2%)]. The rate of MACEs at 30 days in all patients was 9.2%, including 54 (5.6%) deaths. Patients who underwent CAG had a lower rate of MACEs and mortality than those who did not receive CAG (MACEs: 5.6% vs. 13.0%, P < 0.001; mortality: 1.6% vs. 9.8%, P < 0.001). Nonetheless, no statistically significant difference was found in the rates of MACEs and mortality between the early (< 24 h) and delayed (≥ 24 h) CAG groups. Older age (OR: 1.036, 95% CI: 1.007, 1.065, P = 0.014), and acute heart failure (OR: 2.431, 95% CI: 1.244, 4.749, P = 0.009) increased the risk of MACEs and protective factors were underwent CAG (OR: 0.427, 95% CI: 0.219, 0.832, P = 0.012) or PCI (OR: 0.376, 95% CI: 0.163, 0.868, P = 0.022). In the multilevel logistic regression, older age (OR: 0.944, 95% CI: 0.932, 0.957, P < 0.001), cardiogenic shock (OR: 0.233, 95% CI: 0.079, 0.629, P = 0.009), pulmonary moist rales (OR: 0.368, 95% CI: 0.197, 0.686, P = 0.002), and prior chronic kidney disease (OR: 0.070, 95% CI: 0.018, 0.273, P < 0.001) was negatively associated with CAG.ConclusionThis real-world cohort study of NSTEMI patients confirmed that the early invasive strategy did not reduce the incidence of MACEs and mortality within 30 days compared with the delayed invasive strategy in NSTEMI patients.

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“…Noninvasive stress tests for inducible ischemia are recommended before an invasive strategy (Class IA) for suspected ACS with normal ECG results and stable troponin levels [42]. In patients with NSTEMI and unstable angina, a meta-analysis of randomized controlled trials found that early versus delayed invasive management (i.e., coronary angiography) was associated with a lower incidence of major adverse cardiovascular events (MACE) (relative risk (RR) 0.65, 95% confidence intervals (CI) 0.49-0.87; p = 0.003) and recurrent ischemia (RR 0.42, 95%CI 0.26-0.69; p < 0.0005) [43]. However, accessing emergent diagnostic care in ACS is often delayed due to several factors, such as suboptimal patient flow and access to appropriate technologies.…”

Section: Cad Diagnosis-challenges With Access Accuracy and Appropriat...mentioning

confidence: 99%

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

Kodeboina

Piayda

Jenniskens

et al. 2023

IJERPH

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Clinical and economic burdens exist within the coronary artery disease (CAD) care pathway despite advances in diagnosis and treatment and the increasing utilization of percutaneous coronary intervention (PCI). However, research presenting a comprehensive assessment of the challenges across this pathway is scarce. This contemporary review identifies relevant studies related to inefficiencies in the diagnosis, treatment, and management of CAD, including clinician, patient, and economic burdens. Studies demonstrating the benefits of integration and automation within the catheterization laboratory and across the CAD care pathway were also included. Most studies were published in the last 5–10 years and focused on North America and Europe. The review demonstrated multiple potentially avoidable inefficiencies, with a focus on access, appropriate use, conduct, and follow-up related to PCI. Inefficiencies included misdiagnosis, delays in emergency care, suboptimal testing, longer procedure times, risk of recurrent cardiac events, incomplete treatment, and challenges accessing and adhering to post-acute care. Across the CAD pathway, this review revealed that high clinician burnout, complex technologies, radiation, and contrast media exposure, amongst others, negatively impact workflow and patient care. Potential solutions include greater integration and interoperability between technologies and systems, improved standardization, and increased automation to reduce burdens in CAD and improve patient outcomes.

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Meta‐analysis of optimal timing of coronary intervention in non‐ST‐elevation acute coronary syndrome

Cited by 15 publications

References 21 publications

Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq

Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq

Timing of angiography and outcomes in patients with non-ST-segment elevation myocardial infarction: Insights from the evaluation and management of patients with acute chest pain in China registry

Challenges and Burdens in the Coronary Artery Disease Care Pathway for Patients Undergoing Percutaneous Coronary Intervention: A Contemporary Narrative Review

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