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Published on: May 28, 2019
Comparison of Acute Versus Subacute Coronary Angiography in Patients With NON-ST-Elevation Myocardial Infarction
Martin B Rasmussen1, Carsten Stengaard1, Jacob T Sørensen1
1Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark.
Insights
For high-risk acute coronary syndrome without ST-segment elevation, immediate coronary angiography (CAG) showed no benefit over a subacute approach. Early identification and triage of these patients are feasible and safe, potentially improving diagnosis and treatment.
Area of Science:
- Cardiology
- Clinical Trials
- Emergency Medicine
Background:
- Optimal timing for coronary angiography (CAG) in high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) is unclear.
- Existing guidelines lack definitive recommendations for immediate vs. subacute invasive strategies.
Purpose of the Study:
- To compare clinical outcomes in NSTE-ACS patients undergoing acute (<2 hours) versus subacute (<72 hours) CAG.
- To evaluate the feasibility and safety of early prehospital triage for NSTE-ACS.
Main Methods:
- Randomized trial of 496 patients with suspected NSTE-ACS.
- Acute CAG group (n=245) vs. subacute CAG group (n=251).
- Primary endpoint: composite of death, reinfarction, or heart failure readmission within 1 year.
Main Results:
- Median time to revascularization: 1.3 hours (acute) vs. 51.1 hours (subacute).
- No significant difference in the primary composite endpoint (10.2% vs. 11.6%, p=0.62).
- 1-year all-cause mortality was similar between groups (5.7% vs. 5.6%, p=0.96).
Conclusions:
- Neither acute nor subacute CAG significantly impacted the composite endpoint or mortality in NSTE-ACS patients.
- Prehospital identification and direct triage to invasive centers are feasible and safe for NSTE-ACS.
- Early diagnosis and revascularization facilitated by direct triage may improve patient outcomes.
Abstract:
The optimal timing of coronary angiography (CAG) in high-risk patients with acute coronary syndrome without persisting ST-segment elevation (NST-ACS) remains undetermined. The NON-ST-Elevation Myocardial Infarction trial aimed to compare outcomes in NSTE-ACS patients randomized to acute CAG (STEMI-like approach) with patients randomized to medical therapy and subacute CAG. We randomized 496 patients with suspected NST-ACS based on symptoms and significant regional ST depressions and/or elevated point-of-care troponin T (POC-cTnT) (≥50 ng/l) to either acute CAG (<2 hours, n = 245) or subacute CAG (<72 hours, n = 251). The primary end point was a composite of all-cause death, reinfarction, and readmission with congestive heart failure within 1 year from randomization. A final acute coronary syndrome (ACS) diagnosis was assigned to 429 (86.5%) patients. The median time from randomization to revascularization was 1.3 hours in the acute CAG group versus 51.1 hours in the subacute CAG group (p <0.001). The composite end point occurred in 25 patients (10.2%) in the acute CAG group and 29 (11.6%) in the subacute CAG group, p = 0.62. The acute CAG group had a 1-year all-cause mortality of 5.7% compared with 5.6% in the subacute CAG group, p = 0.96. In conclusion, neither the composite end point of all-cause death, reinfarction, and readmission with congestive heart failure nor mortality differed between an acute and subacute CAG approach in NSTE-ACS patients. However, identification of NSTE-ACS patients in the prehospital phase and direct triage to an invasive center is feasible, safe and may facilitate early diagnosis and revascularization.
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