Predictors of Initial Revascularization Versus Medical Therapy Alone in Patients With Non-ST-Segment-Elevation Acute
Harindra C Wijeysundera1, Mandeep S Sidhu2, Maria C Bennell2
1From the Schulich Heart Centre, Division of Cardiology, Sunnybrook Health Sciences Centre (H.C.W., M.C.B., D.T.K., J.V.T.) and Institute of Health Policy, Management and Evaluation (H.C.W., D.T.K., J.V.T.), University of Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Ontario, Canada (H.C.W., F.Q., D.T.K., J.V.T.); Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada (H.C.W.); Samuel S. Stratton VA Medical Center, Albany Medical Center, Albany Medical College, New York (M.S.S., W.E.B.); and Foothills Hospital, University of Calgary, Alberta, Canada (M.L.K.). harindra.wijeysundera@sunnybrook.ca.
Insights
Early revascularization for non-ST-segment-elevation acute coronary syndrome improves survival. Predictors include higher risk presentation and interventional cardiologist performance, with significant survival benefits observed for both PCI and CABG.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Practice Guidelines
Background:
- Invasive strategy is a guideline for non-ST-segment-elevation acute coronary syndromes (NSTE-ACS).
- Wide variation exists in revascularization rates despite early angiography in NSTE-ACS patients.
- Predictors and outcomes of early revascularization versus medical therapy alone require identification.
Purpose of the Study:
- Identify predictors of early revascularization in NSTE-ACS patients undergoing an invasive strategy.
- Assess clinical outcomes associated with revascularization versus medical therapy alone.
- Analyze variation in revascularization rates across healthcare facilities.
Main Methods:
- Retrospective analysis of 50,302 NSTE-ACS patients in Ontario, Canada (2008-2013).
- Assessed revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) within 7 days of angiography.
- Used multivariable logistic and Cox models to identify predictors and assess outcomes.
Main Results:
- 68.2% of patients (34,288) underwent revascularization (28,011 PCI, 6,277 CABG).
- Significant variation in revascularization rates (2-fold) observed across hospitals.
- Higher risk presentation and angiography by an interventional cardiologist predicted revascularization.
- Revascularization (PCI or CABG) significantly improved survival compared to medical therapy.
Conclusions:
- The majority of NSTE-ACS patients undergoing an invasive strategy received revascularization, but rates varied widely.
- Revascularization was associated with significantly improved survival in NSTE-ACS patients.
- Understanding predictors and outcomes is crucial for optimizing NSTE-ACS management.
Background:
Although an invasive strategy is a class I clinical practice guideline for non-ST-segment-elevation acute coronary syndromes, there is wide variation in the proportion of patients who undergo revascularization despite early angiography. We sought to identify the predictors of early revascularization versus medical therapy alone in patients with non-ST-segment-elevation acute coronary syndrome undergoing an invasive strategy and to assess their clinical outcomes.
Methods And Results:
We assessed revascularization status by percutaneous coronary intervention or coronary artery bypass grafting within 7 days of the index angiogram in all patients with non-ST-segment-elevation acute coronary syndrome who underwent an invasive strategy in Ontario, Canada, from October 1, 2008, to October 31, 2013, with follow-up through December 31, 2014. The primary outcome was mortality. Multivariable hierarchical logistic models identified predictors of revascularization, and multivariable Cox models with treatment strategy as a 3-level time-varying covariate assessed the relationship between revascularization status and clinical outcomes. We identified 50 302 patients of whom 34 288 (68.2%) underwent revascularization (percutaneous coronary intervention: 28 011 and coronary artery bypass grafting: 6277). There was a 2-fold variation in revascularization rates across hospitals. A higher risk presentation significantly predicted revascularization (odds ratio, 1.26; 95% confidence interval, 1.18-1.35), as did having the angiogram by an interventional cardiologist (odds ratio, 1.76; 95% confidence interval, 1.57-1.98). Revascularized patients with either percutaneous coronary intervention (hazard ratio, 0.64; 95% confidence interval, 0.60-0.69) or coronary artery bypass grafting (hazard ratio, 0.53; 95% confidence interval, 0.47-0.60) had improved survival compared with medically treated patients.
Conclusions:
Although the majority of patients with non-ST-segment-elevation acute coronary syndrome who underwent an early invasive approach received revascularization, there was wide variation. Revascularization was associated with significantly improved survival.
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