Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary
Esam Elbarasi1, Shaun G Goodman, Raymond T Yan
1Terrence Donnelly Heart Center, Division of Cardiology, St Michael's Hospital, University of Toronto, and Canadian Heart Research Centre, Toronto, Ontario, Canada.
Insights
Patients with prior percutaneous coronary intervention (PCI) for non-ST elevation acute coronary syndrome (NSTE-ACS) received more invasive treatment. Those with prior coronary artery bypass graft surgery (CABG) received less invasive therapy, highlighting a management discrepancy.
Area of Science:
- Cardiology
- Interventional Cardiology
- Acute Coronary Syndromes
Background:
- Contemporary guidelines recommend early invasive strategies for non-ST elevation acute coronary syndrome (NSTE-ACS) patients with prior revascularization.
- Real-world management patterns for these patients remain under-investigated.
Purpose of the Study:
- To analyze the management patterns of NSTE-ACS patients with prior coronary revascularization.
- To compare clinical characteristics and in-hospital procedures based on revascularization history.
Main Methods:
- Analysis of 3 Canadian registries (ACS I, ACS II, GRACE/expanded-GRACE) including 12,483 NSTE-ACS patients (June 1999 - December 2007).
- Stratification into four groups: no prior revascularization, prior percutaneous coronary intervention (PCI) only, prior coronary artery bypass graft surgery (CABG) only, and both PCI and CABG.
- Comparison of clinical characteristics, medication use, and cardiac procedures.
Main Results:
- Patients with prior PCI and/or CABG were more likely male, with diabetes, myocardial infarction, and heart failure.
- Prior PCI was independently associated with increased in-hospital cardiac catheterization (aOR 1.18).
- Prior CABG was independently associated with decreased invasive therapy (aOR 0.77).
Conclusions:
- NSTE-ACS patients with prior PCI were more likely to undergo invasive treatment.
- NSTE-ACS patients with prior CABG received less invasive therapy.
- Further research is needed to assess the appropriateness of this observed treatment discrepancy.
Background:
Contemporary guidelines support an early invasive strategy for non-ST elevation acute coronary syndrome (NSTE-ACS) patients who had prior coronary revascularization. However, little is known about the management pattern of these patients in "real world."
Methods:
We analyzed 3 consecutive Canadian registries (ACS I, ACS II, and Global Registry of Acute Coronary Events [GRACE]/expanded-GRACE) that recruited 12,483 NSTE-ACS patients from June 1999 to December 2007. We stratified the study population according to prior coronary revascularization status into 4 groups and compared their clinical characteristics, in-hospital use of medications, and cardiac procedures.
Results:
Of the 12,483 NSTE-ACS patients, 71.2% had no prior revascularization, 14.2% had percutaneous coronary intervention (PCI) only, 9.5% had coronary artery bypass graft surgery (CABG) only, and 5% had both PCI and CABG. Compared to their counterparts without prior revascularization, patients with previous PCI and/or CABG were more likely to be male, to have diabetes, myocardial infarction, and heart failure but less likely to have ST-segment deviation or positive cardiac biomarker on presentation. Early use of evidence-based medications was higher among patients with previous PCI only and lower among patients with previous CABG only. After adjusting for possible confounders including GRACE risk score, prior PCI was independently associated with in-hospital use of cardiac catheterization (adjusted odds ratio [OR] 1.18, 95% CI 1.04-1.34, P = .008). In contrast, previous CABG was an independent negative predictor (adjusted OR .77, 95% CI 0.68-0.87, P < .001). There was no significant interaction (P = .93) between previous PCI and CABG.
Conclusions:
The NSTE-ACS patients with previous PCI were more likely to be treated invasively. Conversely, patients with prior CABG less frequently received invasive therapy. Future studies should determine the appropriateness of this treatment discrepancy.
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