Elsevier

The American Journal of Cardiology

Volume 136, 1 December 2020, Pages 15-23
The American Journal of Cardiology

Relation of Timing of Percutaneous Coronary Intervention on Outcomes in Patients With Non-ST Segment Elevation Myocardial Infarction

https://doi.org/10.1016/j.amjcard.2020.09.011Get rights and content

International guidelines suggest revascularization within 24 hours in non-ST segment elevation myocardial infarction (NSTEMI). Within a large population cohort study, we aimed to explore clinical practice regarding timing targets for percutaneous coronary intervention (PCI) in NSTEMI. The Victorian Cardiac Outcomes Registry was established in 2013 as a state-wide clinical quality registry, pooling data from public and private PCI capable centers. Data were collected on 11,852 PCIs performed for NSTEMI from 2014 to 2018. Patients were divided into 3 groups by time of symptom onset to PCI (<24 hours; 24 to 72 hours; >72 hours). We performed multivariable logistic regression analysis conditional on several baseline covariates in investigating the impact of timing of PCI in NSTEMI on clinical outcomes. Patients who underwent PCI within 24 hours represented 18.4% (n = 2,178); 24 to 72 hours 45.8% (n = 5,434); >72 hours 35.8% (n = 4,240). Patients waiting longer for PCI were older (62.6 ± 12.2 vs 64.8 ± 12.6 vs 67.0 ± 12.7, p <0.001), more likely to be female (23.1% vs 24.2% vs 26.4%, p = 0.007), and have diabetes (18.6% vs 21.1% vs 27.1%, p <0.001). Multivariate logistic regression found that as compared with PCI <24 hours, PCI 24 to 72 hours and PCI >72 hours of symptom onset were associated with a decreased risk of 30-day mortality (odds ratio 0.55; 95% confidence interval 0.35 to 0.86, p = 0.008 and odds ratio 0.64; 95% confidence interval 0.35 to 1.01, p = 0.053, respectively). There was no significant difference in 30-day mortality between groups following exclusion of patients presenting with cardiogenic shock or out of hospital cardiac arrest requiring intubation. In conclusion, many registry patients undergo PCI outside the 24-hour window following NSTEMI. This delay is at odds with current guideline recommendations but does not appear to be associated with an increased mortality risk.

Section snippets

Methods

VCOR was established in 2013 as a state-wide clinical quality registry in Victoria, Australia, with all 32 public and private PCI capable centers contributing from 2017. VCOR is managed by Monash University and is represented by a steering committee constituted by specialists from contributing centers. The full VCOR methodology is described elsewhere.9 VCOR is ethics approved and operates with an opt-off consent process. Following VCOR research and local institutional ethics committee approvals

Results

Of the 11,852 consecutive patients who underwent PCI for NSTEMI between January 2014 and December 2018, 2,178 (18.4%) underwent PCI <24 hours from symptom onset, 5,434 (45.8%) underwent PCI 24 to 72 hours from symptom onset, and 4,240 (35.8%) underwent PCI >72 hours from symptom onset. Patients waiting longer for PCI were older, more likely to be female, and more commonly had co-morbidities such as diabetes mellitus, peripheral vascular disease, cerebrovascular disease, poor renal function, and

Discussion

This study of a large contemporary cohort of patients who underwent PCI for NSTEMI demonstrated that only 18.4% of patients underwent PCI within the guideline recommended 24-hour window, with 35.8% patients who underwent PCI outside 72 hours. Patients who underwent earlier revascularization had fewer high-risk characteristics overall, apart from those that presented with cardiogenic shock or OHCA requiring intubation. A higher rate of mortality was observed in patients who underwent PCI <24

Authors’ Contributions

Riley J. Batchelor: Conceptualization, Methodology Investigation, Writing – Original Draft, Visualization

Diem Dinh: Methodology, Software, Formal analysis, Data curation, Writing – Review & Editing

Angela Brennan: Data curation, Writing – Review & Editing, Project administration

Nathan Wong: Writing – Review & Editing

Jeffrey Lefkovits: Validation, Data curation, Writing – Review & Editing

Christopher Reid: Validation, Data curation, Writing – Review & Editing

Stephen J. Duffy: Validation, Data

Disclosures

The authors declare that they have no known competing financial interests or personal relations that could have appeared to influence the work reported in this study.

References (17)

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The Victorian Cardiac Outcomes Registry (VCOR) was funded by Medibank Private from 2011 to 2014, in addition the Victorian Department of Health and Human Services have provided funding since 2012, with Monash University providing in-kind funding. Professor Reid is supported by a NHMRC Principal Research Fellowship (reference no. 11136372). Professor Duffy's work is supported by a NHMRC grant (reference no. 1111170). Associate Professor Stub is supported by an NHF Future Leader Fellowship (reference no. 101908), and a Viertel Foundation Clinical Investigator award.

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