Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation
Lior Lupu1, Louay Taha2, Ariel Banai1
1Department of Cardiology, Tel Aviv Sourasky Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Insights
Adherence to European Society of Cardiology guidelines for percutaneous coronary intervention (PCI) in non-ST-segment elevation myocardial infarction (NSTEMI) is low. Most high-risk NSTEMI patients do not receive timely PCI, indicating a gap in guideline implementation.
Area of Science:
- Cardiology
- Interventional Cardiology
- Clinical Practice Guidelines
Background:
- The European Society of Cardiology (ESC) recommends immediate (<2 hours) or early (<24 hours) percutaneous coronary intervention (PCI) for very-high and high-risk patients with non-ST-segment elevation myocardial infarction (NSTEMI), respectively.
- Adherence to these time-sensitive treatment recommendations is crucial for optimizing patient outcomes in NSTEMI management.
Purpose of the Study:
- To evaluate the adherence to ESC guidelines for PCI timing in NSTEMI patients within Israel.
- To investigate potential factors contributing to non-adherence, including the perceived clinical impact of guideline-recommended PCI timing.
Main Methods:
- Analysis of nationwide data from the Acute Coronary Syndrome Israeli Survey (ACSIS) conducted in 2016 and 2018.
- Inclusion of all NSTEMI patients who underwent PCI during the survey periods.
Main Results:
- Of 1793 NSTEMI patients, 1643 (92%) underwent PCI. Immediate PCI was performed in only 6.4% of very-high-risk patients, and early PCI in 32.1%.
- For high-risk NSTEMI patients, early PCI was performed in only 43.9%. Patients experiencing delayed PCI were older and had more comorbidities.
- Acute heart failure was the primary reason for classifying NSTEMI patients as very high-risk (89.1%).
Conclusions:
- Current adherence to ESC guidelines for immediate and early PCI in high-risk NSTEMI patients is suboptimal.
- Significant deviations from recommended PCI timelines were observed, suggesting a need for further investigation into the barriers to guideline implementation.
Background:
The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (non-ST-segment elevation myocardial infarction [NSTEMI]) has recommended immediate (<2 h) percutaneous coronary intervention (PCI) in very-high risk patients and early (<24 h) PCI in high-risk patients.
Hypothesis:
To examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes.
Methods:
All NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis.
Results:
Out of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty-six (14.5%) patients and 922 (85.5%) patients were defined as very high-risk and high-risk NSTEMI patients, respectively. Of the very high-risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high-risk category. Of the high-risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities.
Conclusions:
Despite guidelines recommendations for immediate and early PCI in very high-risk and high-risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high-risk patients.
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