Early versus late percutaneous revascularization in patients hospitalized with non ST-segment elevation myocardial
Sameer Arora1, Kunihiro Matsushita2, Arman Qamar3
1Division of Cardiology, University of North Carolina at Chapel Hill, North Carolina.
Insights
Early percutaneous coronary intervention (PCI) significantly reduces 28-day mortality in high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients. However, long-term survival benefits were not observed compared to delayed PCI.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Outcomes Research
Background:
- Current guidelines suggest early invasive intervention for high-risk non-ST-segment elevation myocardial infarction (NSTEMI) patients.
- A delayed strategy is considered for low-risk patients, but real-world effectiveness remains unclear.
Purpose of the Study:
- To evaluate the real-world effectiveness of early versus late percutaneous coronary intervention (PCI) in NSTEMI patients.
- To assess the association between timing of PCI and short-term and long-term mortality.
Main Methods:
- Analysis of 6,746 NSTEMI patients from the ARIC Study (1987-2012) undergoing PCI.
- Stratification into low-risk and high-risk groups based on TIMI score and clinical factors.
- Multivariable logistic regression to analyze the association between early (<24 hr) versus late (≥24 hr) PCI and mortality, adjusted for confounders.
Main Results:
- Early PCI was associated with a 58% reduction in 28-day mortality for the overall NSTEMI population.
- High-risk patients undergoing early PCI showed a 57% reduction in 28-day mortality.
- No significant difference in 1-year mortality was observed between early and late PCI groups.
Conclusions:
- Early PCI in high-risk NSTEMI patients is linked to improved 28-day survival.
- The study highlights the benefit of timely intervention for acute cardiac events in specific patient populations.
Background:
Current guidelines recommend early invasive intervention (<24 hr) for high risk patients with non-ST-segment elevation myocardial infarction (NSTEMI). A delayed invasive strategy (24-72 hr) is considered reasonable for low risk patients. The real-world effectiveness of this strategy is unknown.
Methods:
The ARIC Study has conducted hospital surveillance of acute myocardial infarction (MI) since 1987. NSTEMI was classified using a validated algorithm. We limited our study to patients undergoing early (<24 hr of the event onset), or late (≥24 hr) percutaneous coronary intervention (PCI). Patients were stratified into low (TIMI score 2-4), and high risk (TIMI score 5-7, or presence of cardiogenic shock, ventricular fibrillation, or cardiac arrest). Associations between early versus late PCI and mortality were analyzed using multivariable logistic regression adjusted for demographics, hospitalization year, TIMI score, and comorbidities.
Results:
From 1987 to 2012, 6,746 patients were hospitalized with NSTEMI and underwent PCI. Most were white (79%), male (68%), with mean age 61 years. The 28-day and 1-year mortality were 2% and 5%, respectively. Most revascularizations (65%) were late. After accounting for potential confounders, early PCI was associated with a 58% reduced 28-day mortality (OR = 0.42; 95% CI: 0.21-0.84) for the entire population, and 57% reduced mortality (OR = 0.43; 95% CI: 0.21-0.88) for high risk patients. By 1-year of follow up, there was no significant difference in mortality with respect to early vs. late PCI.
Conclusion:
In hospitalized NSTEMI patients with high risk of clinical events, early PCI is associated with improved 28-day survival.
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