Outcomes of Patients Receiving Downstream Revascularization After Initial Medical Management for Non-ST-Segment
Tomoya T Hinohara1, Matthew T Roe2, Harvey D White3
1Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina.
Insights
Patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) initially treated medically may later need revascularization. This group faces higher risks of ischemic events and major bleeding compared to those not revascularized.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Trials
Background:
- Non-ST-segment elevation acute coronary syndromes (NSTE ACS) are often managed medically.
- A subset of NSTE ACS patients initially managed medically may require later revascularization.
- Outcomes for NSTE ACS patients undergoing downstream revascularization are not well-characterized.
Purpose of the Study:
- To compare outcomes between NSTE ACS patients who underwent downstream revascularization versus those who did not.
- To identify characteristics of NSTE ACS patients requiring later revascularization.
- To evaluate ischemic and bleeding events in medically managed NSTE ACS patients based on subsequent revascularization.
Main Methods:
- Analysis of TRILOGY ACS trial data, randomizing 9,326 NSTE ACS patients to prasugrel or clopidogrel.
- Comparison of patient characteristics and outcomes (ischemic and bleeding) between patients with and without downstream revascularization.
- Follow-up through 30 months to assess outcomes after index hospitalization.
Main Results:
- 7.1% of medically managed NSTE ACS patients underwent downstream revascularization (PCI or CABG) at a median of 121 days.
- Revascularized patients were younger, more likely male, and had more comorbidities (hyperlipidemia, diabetes, prior MI/revascularization).
- Downstream revascularization was associated with significantly higher rates of composite ischemic events (CV death, MI, stroke) and major bleeding.
Conclusions:
- A small but significant proportion of NSTE ACS patients initially managed medically require downstream revascularization.
- These patients experience substantially higher rates of adverse ischemic and bleeding outcomes.
- No significant difference in outcomes was observed between prasugrel and clopidogrel treatments in this subgroup.
Abstract:
Patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) are sometimes treated with medical management alone rather than an invasive strategy. Among those medically managed without revascularization and discharged, a proportion will require revascularization later on, but little is known about this population. In TRILOGY ACS, 9,326 patients with NSTE ACS who were selected for medical management alone were randomized to treatment with prasugrel or clopidogrel and discharged without revascularization. Patient characteristics and ischemic and bleeding outcomes through 30 months were compared between patients who underwent downstream revascularization after the index hospitalization and those who did not. A total of 662 patients (7.1%) underwent later revascularization by percutaneous coronary intervention (73.1%), coronary artery bypass graft surgery (26.4%), or the two (0.5%). Median time to revascularization was 121 days (twenty-fifth, seventy-fifth percentiles: 41, 326). Revascularized patients were younger, more likely to be male, and had higher rates of hyperlipidemia, diabetes mellitus, prior myocardial infarction, and prior revascularization compared with those not revascularized. Europe and North America had the highest rates of revascularization. During the follow-up period, those who underwent revascularization had a higher rate of the composite outcome of cardiovascular death, myocardial infarction, or stroke occurring after revascularization compared with those not revascularized (hazard ratio [HR] 2.73 [95% confidence interval {CI} 2.21 to 3.38], p < 0.001) as well as a higher rate of each of the individual outcomes. Major bleeding was also higher in those who underwent revascularization (GUSTO severe or life-threatening: HR 2.61 [95% CI 1.02 to 6.67], p = 0.045; TIMI major: HR 2.24 [95% CI 1.12 to 4.48], p = 0.022). There was no evidence that bleeding and ischemic outcomes varied by treatment with clopidogrel versus prasugrel. In conclusion, among patients initially medically managed after NSTE ACS, a small proportion later require revascularization and have a high rate of ischemic and major bleeding outcomes compared with those not requiring downstream revascularization.
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