Skip to main content

Advertisement

Log in

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

  • Original Paper
  • Published:
Clinical Research in Cardiology Aims and scope Submit manuscript

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 (< 24 h) 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.

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 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)].

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 < 140 with established NSTEMI or ST/T-segment changes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

ACS:

Acute coronary syndrome

MACE:

Major adverse cardiac events

NSTEACS:

Non-ST-segment elevation acute coronary syndrome

NSTEMI:

Non-ST-segment elevation myocardial infarction

References

  1. Jorgensen T, Capewell S, Prescott E et al (2013) Population-level changes to promote cardiovascular health. Eur J PrevCardiol 20:409–421. https://doi.org/10.1177/2047487312441726

    Article  Google Scholar 

  2. Go AS, Mozaffarian D, Roger VL et al (2013) Heart disease and stroke statistics 2013 up- date: a report from the American Heart Associaton. Circulation 127:e6–e245. https://doi.org/10.1161/CIR.0b013e31828124ad

    Article  PubMed  Google Scholar 

  3. Collet J-P, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL et al (2020) ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2020:1–79. https://doi.org/10.1093/eurheartj/ehaa575

    Article  Google Scholar 

  4. Amsterdam EA, Wenger NK, Brindis RG et al (2014) 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American college of cardiology/American heart association task force on practice guidelines. J Am CollCardiol 64:190–228. https://doi.org/10.1016/j.jacc.2014.09.017

    Article  Google Scholar 

  5. Mehta SR, Granger CB, Boden WE, TIMACS Investigators et al (2009) Early versus delayed invasive intervention in actue coronary syndromes. N Engl J Med 360:2165–2175. https://doi.org/10.1056/NEJMoa0807986

    Article  CAS  PubMed  Google Scholar 

  6. Kofoed K, Kelbæk H, Hansen PR et al (2018) Early versus standard care invasive examination and treatment of patients with non-ST-segment elevation acute coronary syndrome: the VERDICT (Very EaRIly vs deferred invasive evaluation using computerized tomography)- randomized controlled trial. Circulation 138:2741–2750. https://doi.org/10.1161/CIRCULATIONAHA.118.037152

    Article  PubMed  Google Scholar 

  7. Lemesle G, Laine M, Pankert M et al (2020) Optimal timing of intervention in NSTE-ACS without pre-treatment: the EARLY randomized trial. JACC CardiovascInterv 13:907–917. https://doi.org/10.1016/j.jcin.2020.01.231

    Article  Google Scholar 

  8. Sorajja P, Gersh BJ, Cox DA et al (2010) Impact of delay to angioplasty in patients with acute coronary syndromes undergoing invasive management: analysis from the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial. J Am CollCardiol 55:1416–1424. https://doi.org/10.1016/j.jacc.2009.11.063

    Article  CAS  Google Scholar 

  9. ÁlvarezÁlvarez B, AbouJokh Casas C, Cordero A et al (2020) Early revascularization and long-term mortality in high-risk patients with non–ST-elevation myocardial infarction. The CARDIOCHUS-HUSJ registry. Rev EspCardiol 73:35–42. https://doi.org/10.1016/j.rec.2019.02.015

    Article  Google Scholar 

  10. Arora S, Matsushita K, Qamar A et al (2018) Early versus late percutaneous revascularization in patients hospitalized with non-ST-segment elevation myocardial infarction: the atherosclerosis risk in communities surveillance study. Catheter CardiovascInterv 91:253–259. https://doi.org/10.1002/ccd.27156

    Article  Google Scholar 

  11. Montalescot G, Dabbous OH, Lim MJ et al (2005) Global registry of acute coronary events investigators. Am J Cardiol 95:1397–1403. https://doi.org/10.1016/j.ahj.2009.06.003

    Article  PubMed  Google Scholar 

  12. Ryan JW, Peterson ED, Chen AY, CRUSADE Investigators et al (2005) Optimal timing of intervention in non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE (Can Rapid risk stratification of Unstable angina pectoris Suppress Adverse outcomes with Early implementation of the ACC/AHA guide- lines) Registry. Circulation 11:3049–3057. https://doi.org/10.1161/CIRCULATIONAHA.105.582346

    Article  Google Scholar 

  13. Riezebos RK, Ronner E, Bals T, OPTIMA Trial et al (2009) Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes. Heart 95:807–812. https://doi.org/10.1136/hrt.2008.154815

    Article  CAS  PubMed  Google Scholar 

  14. Montalescot G, Cayla G, Collet JP, ABOARD Investigators et al (2009) Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trials. JAMA 302:947–954. https://doi.org/10.1001/jama.2009.1267

    Article  CAS  PubMed  Google Scholar 

  15. Katritsis DG, Siontis GCM, Kastrati A et al (2011) Optimal timing of coronary angiography and potential intervention in non-ST-elevation acute coronary syndromes. Eur Heart J 32:32–40. https://doi.org/10.1093/eurheartj/ehq276

    Article  PubMed  Google Scholar 

  16. Navarese EP, Gurbel PA, Andreotti F et al (2013) Optimal timing of coronary invasive strategy in non-ST-segment elevation acute coronary syndromes: a systematic review and meta-analysis. Ann Intern Med 158:261–270. https://doi.org/10.7326/0003-4819-158-4-201302190-00006

    Article  PubMed  Google Scholar 

  17. Jobs A, Mehta SR, Montalescot G et al (2017) Optimal timing of an invasive strategy in patients with non-ST-elevation acute coronary syndrome: a meta-analysis of randomised trials. Lancet 390:737–746. https://doi.org/10.1016/S0140-6736(17)31490-3

    Article  PubMed  Google Scholar 

  18. Deharo P, Ducrocq G, Bode C et al (2017) Timing of angiography and outcomes in high- risk patients with non-ST-segment-elevation myocardial infarction managed invasively. Circulation 136:1895–1907. https://doi.org/10.1161/CIRCULATIONAHA.117.029779

    Article  PubMed  Google Scholar 

  19. Bonello L, Laine M, Puymirat E et al (2016) Timing of coronary invasive strategy in non- ST-segment elevation acute coronary syndromes and clinical outcomes: an updated meta-analysis. JACC CardiovascInterv 9:2267–2276. https://doi.org/10.1016/j.jcin.2016.09.017

    Article  Google Scholar 

  20. Milosevic A, Vasiljevic-Pokrajcic Z, Milasinovic D et al (2016) Immediate versus delayed invasive intervention for non-STEMI patients: the RIDDLE-NSTEMI Study. JACC CardiovascInterv 9:541–549. https://doi.org/10.1016/j.jcin.2015.11.018

    Article  Google Scholar 

  21. Rosenbaum PR, Rubin DB (1984) Reducing bias in observational studies using subclassification on the propensity score. Am J Stat Assoc 79:516–524. https://doi.org/10.1080/01621459.1984.10478078

    Article  Google Scholar 

  22. Xie J, Liu C (2005) Adjusted Kaplan-Meier estimator and log-rank test with inverse probability of treatment weighting for survival data. Stat Med 24:3089–3110. https://doi.org/10.1002/sim.2174

    Article  PubMed  Google Scholar 

Download references

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Author information

Authors and Affiliations

Authors

Contributions

The authors contributed equally to this study.

Corresponding author

Correspondence to Jesús Martinón-Martínez.

Ethics declarations

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Martinón-Martínez, J., Álvarez Álvarez, B., González Ferrero, T. et al. 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. Clin Res Cardiol 110, 1464–1472 (2021). https://doi.org/10.1007/s00392-021-01829-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00392-021-01829-8

Keywords

Navigation