Timing of Angiography and Outcomes in High-Risk Patients With Non–ST-Segment–Elevation Myocardial Infarction Managed Invasively

Deharo, Pierre; Ducrocq, Grégory; Bode, Christoph; Cohen, Marc; Cuisset, Thomas; Mehta, Shamir R.; Pollack, Charles V.; Wiviott, Stephen D.; Elbez, Yedid; Sabatine, Marc S.; Steg, Philippe Gabríel

doi:10.1161/circulationaha.117.029779

Cited by 32 publications

(25 citation statements)

References 16 publications

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“…Provision of coronary angiography within 72 hours for NSTEMI showed the greatest sex discrepancy in QI attainment (12.5% lower for women than men). While the Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes (ICTUS) trial did not demonstrate a benefit for an early invasive strategy compared with a selective invasive strategy,19 in patients with high-risk NSTEMI early angiography has been shown to be associated with a lower risk of death and AMI,20 21 and therefore suboptimal attainment of this QI could potentially be associated with adverse outcomes. For STEMI, provision of timely reperfusion revealed a much smaller sex discrepancy which may, in part, be explained by differences in treatment pathways.…”

Section: Discussionmentioning

confidence: 99%

Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Wilkinson

Bebb

Dondo

et al. 2018

Heart

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AimTo investigate sex differences in acute myocardial infarction (AMI) guideline-indicated care as defined by the European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) quality indicators.MethodsNationwide cohort study comprising 691 290 AMI hospitalisations in England and Wales (n=233 hospitals) from the Myocardial Ischaemia National Audit Project between 1 January 2003 and 30 June 2013.ResultsThere were 34.5% (n=238 489) women (median age 76.7 (IQR 66.3–84.0) years; 33.9% (n=80 884) ST-elevation myocardial infarction (STEMI)) and 65.5% (n=452 801) men (median age 67.1 (IQR 56.9–77.2) years; 42.5% (n=192 229) STEMI). Women less frequently received 13 of the 16 quality indicators compared with men, including timely reperfusion therapy for STEMI (76.8% vs 78.9%; p<0.001), timely coronary angiography for non-STEMI (24.2% vs 36.7%; p<0.001), dual antiplatelet therapy (75.4% vs 78.7%) and secondary prevention therapies (87.2% vs 89.6% for statins, 82.5% vs 85.6% for ACE inhibitor/angiotensin receptor blockers and 62.6% vs 67.6% for beta-blockers; all p<0.001). Median 30-day Global Registry of Acute Coronary Events risk score adjusted mortality was higher for women than men (median: 5.2% (IQR 1.8%–13.1%) vs 2.3% (IQR 0.8%–7.1%), p<0.001). An estimated 8243 (95% CI 8111 to 8375) deaths among women could have been prevented over the study period if their quality indicator attainment had been equal to that attained by men.ConclusionAccording to the ESC ACCA AMI quality indicators, women in England and Wales less frequently received guideline-indicated care and had significantly higher mortality than men. Greater attention to the delivery of recommended AMI treatments for women has the potential to reduce the sex-AMI mortality gap.

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Section: Discussionmentioning

confidence: 99%

Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Wilkinson

Bebb

Dondo

et al. 2018

Heart

View full text Add to dashboard Cite

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“…A large-scale meta-analysis included 5324 patients from eight trials and found that an early invasive strategy was associated with a lower mortality among high-risk patients, including those with elevated cardiac biomarkers at baseline, diabetes mellitus, a GRACE risk score more than 140 and aged 75 years 8. Consistently, a recent randomised trial showed that coronary angiography within the initial 12 hours was related to a lower risk of ischaemic outcomes among high-risk patients 9. Therefore, early risk assessment enables high-risk patients with NSTEMI to receive revascularisation as soon as possible and may help improve their outcomes.…”

Section: Discussionmentioning

confidence: 90%

“…A large-scale meta-analysis found that among high-risk patients with NSTEMI, an early invasive strategy was associated with a lower in-hospital mortality 8. In addition, there is evidence indicating that among high-risk patients with NSTEMI, coronary angiography early within the initial 12 hours was associated with better outcomes 9…”

Section: Introductionmentioning

confidence: 99%

Simple risk score based on the China Acute Myocardial Infarction registry for predicting in-hospital mortality among patients with non-ST-segment elevation myocardial infarction: results of a prospective observational cohort study

Song

et al. 2019

BMJ Open

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ObjectivesTo simplify our previous risk score for predicting the in-hospital mortality risk in patients with non-ST-segment elevation myocardial infarction (NSTEMI) by dropping laboratory data.DesignProspective cohort.SettingMulticentre, 108 hospitals across three levels in China.ParticipantsA total of 5775 patients with NSTEMI enrolled in the China Acute Myocardial Infarction (CAMI) registry.Primary outcome measuresIn-hospital mortality.ResultsThe simplified CAMI-NSTEMI (SCAMI-NSTEMI) score includes the following nine variables: age, body mass index, systolic blood pressure, Killip classification, cardiac arrest, ST-segment depression on ECG, smoking status, previous angina and previous percutaneous coronary intervention. Within both the derivation and validation cohorts, the SCAMI-NSTEMI score showed a good discrimination ability (C-statistics: 0.76 and 0.83, respectively); further, the SCAMI-NSTEMI score had a diagnostic performance superior to that of the Global Registry of Acute Coronary Events risk score (C-statistics: 0.78 and 0.73, respectively; p<0.0001 for comparison). The in-hospital mortality increased significantly across the different risk groups.ConclusionsThe SCAMI-NSTEMI score can serve as a useful tool facilitating rapid risk assessment among a broader spectrum of patients admitted owing to NSTEMI.Trial registration numberNCT01874691.

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“…Finally, 12 studies of 9 trials that satisfied our selection criteria were included, involving a total of 8586 patients (Figure 1). 6,8–18 Three trials, namely, OPTIMA, ELISA-3, and RIDDLE-NSTEMI, were updated with long-term follow-up clinical outcomes at 5, 2, and 3 years, respectively. 11,12,14–17 Studies in which coronary intervention was performed 12 hours or later after hospitalization or there was randomization in the early invasive strategy were not included.…”

Section: Resultsmentioning

confidence: 99%

Early invasive strategy for non-ST elevation acute coronary syndrome: a meta-analysis of randomized, controlled trials

et al. 2020

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Objective Patients with non-ST elevation acute coronary syndrome (NSTE-ACS) benefit from coronary intervention, but the optimal timing for an invasive strategy is not well defined. This study aimed to determine whether an early invasive strategy (<12 hours) is superior to a delayed invasive strategy. Methods Twelve studies of nine randomized, controlled trials of 8586 patients were included. Results There were no significant differences in all-cause death (risk ratio [95% confidence interval]) (0.90, [0.77–1.06), re-myocardial infarction (re-MI) (0.95 [0.70–1.29]), major bleeding (0.97 [0.77–1.23]), and refractory ischemia (0.74 [0.53–1.05]) when we compared use of early and delayed invasive strategies. Furthermore, analysis of the effect of the chosen strategy on high-risk patients showed that the rate of composite death or re-MI was significantly decreased in patients with either a Global Registry of Acute Coronary Events (GRACE) risk score >140 or with elevated troponin levels (risk ratio 0.82 [0.72–0.92]; risk ratio 0.84 [0.76–0.93], respectively). Conclusions This meta-analysis shows that an early angiographic strategy does not improve clinical outcome in patients with NSTE-ACS. An early invasive strategy might reduce the rate of composite death or re-MI in high-risk patients with GRACE risk scores >140 or elevated cardiac markers.

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Timing of Angiography and Outcomes in High-Risk Patients With Non–ST-Segment–Elevation Myocardial Infarction Managed Invasively

Abstract: In patients with high-risk NSTEMI, undergoing CAG within the initial 12 hours after admission (as opposed to later, either 12-24 or ≥24 hours) was associated with lower risk of ischemic outcomes at 180 days.

Cited by 32 publications

References 16 publications

Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Sex differences in quality indicator attainment for myocardial infarction: a nationwide cohort study

Simple risk score based on the China Acute Myocardial Infarction registry for predicting in-hospital mortality among patients with non-ST-segment elevation myocardial infarction: results of a prospective observational cohort study

Early invasive strategy for non-ST elevation acute coronary syndrome: a meta-analysis of randomized, controlled trials

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