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Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome, a report from GUSTO
J P Ottervanger1, P Armstrong, E S Barnathan
1Erasmus Medical Center, University Hospital Rotterdam, Room H 560, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands.
Insights
Early revascularization improves survival in acute coronary syndromes (ACS) without ST elevation. Patients undergoing procedures within 30 days had significantly lower one-year mortality compared to those receiving only medical treatment.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Acute coronary syndromes (ACS) without ST elevation require careful treatment strategies.
- Evidence for early revascularization benefits in ACS without ST elevation is inconsistent.
- Further data are needed to clarify the role of invasive procedures.
Purpose of the Study:
- To investigate the effect of early revascularization on one-year survival in ACS patients without ST elevation.
- To compare outcomes between patients who underwent revascularization and those treated medically within 30 days.
Main Methods:
- Analysis of the GUSTO IV ACS trial data, including 7800 patients with ACS without ST elevation.
- Comparison of one-year mortality between patients revascularized within 30 days and those treated medically.
- Statistical adjustments for patient characteristics and propensity scores for revascularization.
Main Results:
- 30% of 7496 30-day survivors underwent revascularization (CABG, PCI, or both) within 30 days.
- Revascularized patients had significantly lower one-year mortality (2.3%) compared to medically treated patients (5.6%).
- Multivariable analysis showed a 47% reduced relative risk of one-year mortality with revascularization (RR 0.53).
Conclusions:
- Early revascularization within 30 days is associated with improved prognosis in ACS without ST elevation.
- High mortality in medically treated patients suggests potential issues with patient selection.
- Further research is warranted to optimize outcomes for medically treated ACS patients.
Background:
Immediate, as well as early, revascularisation is of benefit in patients with acute coronary syndromes (ACS) presenting with ST elevation. However, trials comparing invasive versus medical treatment in patients with an acute coronary syndrome without ST elevation do not consistently show improvement in survival after revascularisation. Accordingly, additional data are warranted.
Methods:
The effect of revascularisation within 30 days on one-year survival in the GUSTO IV ACS trial was investigated. A total of 7800 patients were included with an acute coronary syndrome without ST elevation, documented by either elevated cardiac troponin or transient or persistent ST-segment depression. In this trial, comparing abciximab versus placebo as initial medical therapy, coronary angiography within 60 h after randomisation was discouraged. In 30-day survivors, those who underwent revascularisation were compared with 30-day survivors without revascularisation. Adjustments were made for patient characteristics, and for a propensity score that was adjusted for covariates associated with the likelihood of early revascularisation.
Findings:
Of the 7496 patients who survived at least 30 days, 2265 (30%) underwent coronary revascularisation within 30 days: 789 patients CABG, 1450 PCI and 26 both CABG and PCI. Procedure-related mortality was low at 1.8%. Patients with revascularisation had a lower one-year mortality compared to medically treated patients (2.3% vs. 5.6%, p < 0.001). After multivariable analyses, patients with revascularisation had a relative risk of subsequent mortality within 1 year of 0.53 (95% CI 0.37-0.77) compared to patients without revascularisation.
Conclusions:
Revascularisation within 30 days is associated with an improved prognosis in ACS without ST-segment elevation. The relative high mortality in medically treated patients may be related in part to patient selection, but warrants further studies to improve outcome of these patients.
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