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Published on: May 28, 2019
Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes
R K Riezebos1, E Ronner, E Ter Bals
1Onze Lieve Vrouwe Gasthuis, Department of Interventional Cardiology, Amsterdam, The Netherlands. R.K.Riezebos@xs4all.nl
Insights
For non-ST-segment elevation acute coronary syndromes (NSTE-ACS), delaying percutaneous coronary intervention (PCI) for 24-48 hours significantly reduced myocardial infarction rates compared to immediate PCI. This deferred strategy is recommended for high-risk patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Current acute coronary syndromes (ACS) management often favors early invasive procedures based on retrospective data.
- There is a need to evaluate optimal timing for interventions in non-ST-segment elevation ACS (NSTE-ACS).
Purpose of the Study:
- To compare the efficacy of immediate versus deferred percutaneous coronary intervention (PCI) in patients with NSTE-ACS.
- To assess the impact of intervention timing on clinical outcomes within 30 days and 6 months.
Main Methods:
- A randomized, prospective multicenter trial involving 142 NSTE-ACS patients eligible for PCI.
- Patients were randomized to immediate PCI or deferred PCI (24-48 hours).
- All patients received aggressive antithrombotic therapy including glycoprotein IIb/IIIa inhibitors, aspirin, and clopidogrel.
Main Results:
- The primary endpoint (death, MI, or unplanned revascularization) occurred in 60% with immediate PCI versus 39% with deferred PCI (p=0.004).
- Myocardial infarction (MI) was significantly higher in the immediate PCI group (60% vs. 38%, p=0.005).
- Unplanned revascularization rates were similar between groups; the difference in outcomes persisted at 6 months.
Conclusions:
- Immediate PCI in NSTE-ACS patients is associated with a higher risk of MI compared to a deferred 24-48 hour strategy.
- A delayed PCI approach appears safer for high-risk, non-refractory NSTE-ACS patients.
- Current guidelines may need revision regarding the timing of PCI in NSTE-ACS.
Background:
The field of acute coronary syndromes is characterised by an increasing tendency towards early invasive catheter-based diagnostics and therapeutics-a practice based on observational and retrospective data.
Objective:
To compare immediate versus deferred angioplasty in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) METHODS: A randomised, prospective multicentre trial was performed in patients admitted with NSTE-ACS, eligible for percutaneous coronary intervention (PCI). Interim analysis was performed after enrolment of 251 patients; PCI was appropriate in 142 patients. These patients were randomised to immediate PCI (n = 73) or deferred PCI (24-48 h) (n = 69). Patients received protocol-driven glycoprotein IIb/IIIa blockers, aspirin and clopidogrel. The primary end point was a composite of death, non-fatal myocardial infarction (MI) or unplanned revascularisation, at 30 days. After hospital discharge outpatient follow-up was performed at 30 days and 6 months.
Results:
The incidence at 30 days of the primary end point was 60% in the group receiving immediate PCI and 39% in the group receiving deferred PCI (relative risk (RR) = 1.5, 95% CI 1.09 to 2.15; p = 0.004). No deaths occurred in either group. MI was significantly more common in the group receiving immediate PCI (60% vs 38%, RR = 1.6, 95% CI 1.12 to 2.28, p = 0.005). Unplanned revascularisation was similar in both groups. The observed difference was preserved over 6-months' follow-up.
Conclusions:
Immediate PCI was associated with an increased rate of MI in comparison with a 24-48 h deferred strategy, despite aggressive antithrombotic treatment. The results suggest that PCI for high-risk patients with non-refractory NSTE-ACS should be delayed for at least 24 h after hospital admission.
Trial Registration Number:
ISRCTN80874637.
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