Immediate vs delayed intervention for acute coronary syndromes: a randomized clinical trial
Gilles Montalescot1, Guillaume Cayla, Jean-Philippe Collet
1Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Boulevard de l'Hôpital, 75013 Paris, France. gilles.montalescot@psl.aphp.fr
Insights
Immediate intervention for acute coronary syndromes without ST-segment elevation did not reduce myocardial infarction compared to delayed intervention. The study found no significant difference in peak troponin levels or key secondary endpoints between the two strategies.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- International guidelines suggest early invasive strategies for high-risk acute coronary syndromes (ACS) without ST-segment elevation.
- However, the optimal timing for intervention in these patients remains uncertain.
Purpose of the Study:
- To compare the effectiveness of immediate versus delayed intervention in reducing myocardial infarction (MI) in patients with ACS without ST-segment elevation.
- Investigate if immediate intervention on admission leads to better outcomes than delayed intervention.
Main Methods:
- The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study was a randomized clinical trial.
- 352 patients with ACS without ST-segment elevation and TIMI score ≥3 were randomized to immediate intervention or delayed intervention (next working day, 8-60 hours after enrollment).
- Primary endpoint: peak troponin level; Key secondary endpoint: composite of death, MI, or urgent revascularization at 1-month.
Main Results:
- Immediate intervention involved randomization to sheath insertion within 70 minutes, while delayed intervention averaged 21 hours.
- No significant difference was observed in the primary endpoint (peak troponin I levels) between immediate and delayed intervention groups (P = .70).
- The key secondary endpoint occurred in 13.7% of the immediate group versus 10.2% of the delayed group (P = .31), with no significant difference in other endpoints or major bleeding.
Conclusions:
- In patients with ACS without ST-segment elevation, immediate intervention did not result in a reduction of myocardial infarction compared to a strategy of intervention deferred to the next working day (mean, 21 hours).
- The study suggests that a delayed intervention strategy is not inferior to immediate intervention regarding myocardial infarction as defined by peak troponin levels.
Context:
International guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.
Objective:
To determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.
Design, Setting, And Patients:
The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, a randomized clinical trial that assigned, from August 2006 through September 2008 at 13 centers in France, 352 patients with acute coronary syndromes without ST-segment elevation and a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or more to receive intervention either immediately or on the next working day (between 8 and 60 hours after enrollment).
Main Outcome Measures:
The primary end point was the peak troponin value during hospitalization; the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1-month follow-up.
Results:
Time from randomization to sheath insertion was 70 minutes with immediate intervention vs 21 hours with delayed intervention. The primary end point did not differ between the 2 strategies (median [interquartile range] troponin I value, 2.1 [0.3-7.1] ng/mL vs 1.7 [0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The key secondary end point was observed in 13.7% (95% confidence interval, 8.6%-18.8%) of the group assigned to receive immediate intervention and 10.2% (95% confidence interval, 5.7%-14.6%) of the group assigned to receive delayed intervention (P = .31). The other end points, as well as major bleeding, did not differ between the 2 strategies.
Conclusion:
In patients with acute coronary syndromes without ST-segment elevation, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in myocardial infarction as defined by peak troponin level.
Trial Registration:
clinicaltrials.gov Identifier: NCT00442949.
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