Preinfarct Health Status and the Use of Early Invasive Versus Ischemia-Guided Management in Non-ST-Elevation Acute
Mohammed Qintar1, Kim G Smolderen2, Paul S Chan1
1Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
Insights
Patients with non-ST-elevation myocardial infarction (NSTEMI) who had worse health status or higher risk scores were less likely to receive early invasive management, despite potential benefits. This highlights a gap in NSTEMI treatment strategies.
Area of Science:
- Cardiology
- Clinical Research
- Health Services Research
Background:
- Early invasive management improves outcomes for non-ST-elevation myocardial infarction (NSTEMI).
- The impact of pre-infarction health status on the selection of NSTEMI patients for early invasive management remains unclear.
- Understanding factors influencing treatment decisions is crucial for optimizing patient care.
Purpose of the Study:
- To investigate the association between pre-infarction health status and quality of life with early invasive management in NSTEMI patients.
- To examine the relationship between the Global Registry of Acute Coronary Events (GRACE) risk score and referral for early invasive treatment.
- To identify potential disparities in NSTEMI management based on patient characteristics.
Main Methods:
- Analysis of data from two large US multicenter registries: the Prospective Registry Evaluating outcomes after Myocardial Infarctions (PREPARED) and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status (TRIUMPH).
- Evaluation of pre-infarction angina frequency and quality of life using the Seattle Angina Questionnaire.
- Poisson regression was used to assess associations with early invasive management (coronary angiography within 48 hours), adjusting for confounders.
Main Results:
- Of 3,768 NSTEMI patients, 57.9% received early invasive treatment.
- Patients with better baseline quality of life due to angina were more likely to undergo early angiography (adjusted RR 1.09-1.14).
- Patients in the highest GRACE risk decile had significantly lower rates of early invasive treatment (42.7%) compared to the lowest decile (67.6%).
Conclusions:
- In a real-world NSTEMI cohort, patients with higher mortality risk and poorer health status were less likely to be referred for early invasive management.
- These findings suggest potential undertreatment of high-risk NSTEMI patients based on their pre-infarction condition.
- Further research is needed to understand and address the role of pre-infarction health status in guiding in-hospital treatment strategies for NSTEMI.
Abstract:
Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). The association between preinfarct health status and the selecting patients for early invasive management is unknown. The Prospective Registry Evaluating outcomes after Myocardial Infarctions: Events and Recovery and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status are consecutive US multicenter registries, in which the associations between preinfarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the Global Registry of Acute Coronary Events (GRACE) risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. Of 3,768 patients with NSTEMI, 2,182 (57.9%) patients were referred for early invasive treatment. Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life because of angina (62.1.0%, 60.9%, 59.6%, vs 51.2%; adjusted relative risk [RR] = 1.09, 95% confidence interval [CI] 1.04 to 1.16; RR = 1.13, 95% CI 1.01 to 1.27; RR 1.14, 95% CI 0.99 to 1.31, respectively). Finally, patients with a GRACE score in the highest risk decile (199.5 to <321.4) had significantly lower rates of early invasive treatment (42.7%) than patients in the lowest decile of risk (67.6%; adjusted RR for continuous GRACE score per SD [1 SD = 40 points], 0.96, 95% CI 0.92 to 0.99, p = 0.019). In conclusion, in this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Further work is needed to understand the role of preinfarct health status and in-hospital treatment strategy.
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