Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

Abstract

BackgroundAn early invasive strategy (EIS) is recommended in high-risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS), defined as coronary angiography (CAG), within 24 h of admission. The aim of the present study is to investigate guideline adherence, patient characteristics associated with timing of the intervention and clinical outcome.MethodsIn a prospective registry, the use and timing of CAG and the characteristics and clinical outcome associated with timing were evaluated in high-risk ACS patients. The outcome of early versus delayed invasive strategy (DIS) was compared.ResultsBetween 2006 and 2014, 2,299 high-risk NSTE-ACS patients were included. The use of CAG increased from 77% in 2006 to 90% in 2014 (p trend <0.001) together with a decrease of median time to CAG from 23.3 to 14.5 h (p trend <0.001) and an increase of patients undergoing EIS from 50 to 60% (p trend = 0.002). Patient factors independently related to DIS were higher GRACE risk score, higher age and the presence of comorbidities. No difference was found in incidence of mortality, reinfarction or bleeding at 30-day follow-up. All-cause mortality at 1‑year follow-up was 4.1% vs 7.0% in EIS and DIS respectively (hazard ratio 1.67, 95% confidence interval 1.12–2.49) but was comparable after adjustment for confounding factors.ConclusionThe percentage of high-risk NSTE-ACS patients undergoing CAG and EIS has increased in the last decade. In contrast to the guidelines, patients with a higher risk profile are less likely to undergo EIS. However, no difference in outcome after 30 days and 1 year was found after multivariate adjustment for this higher risk.

Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective

“…Current study compared timing to catheterization between both age categories according to their GRACE risk class, despite that patients at low and intermediate GRACE risk classes were more to be catheterized in the younger age group, while at high GRACE risk class, the elderly were catheterized more and at earlier timing than their younger counterparts; however, the rate of use of early invasive strategy in high GRACE risk class in total is much lower than reported in literature [ 36 ] despite the better prognostic benefit with early invasive strategy (within 24 h) in high-risk NSTE-ACS in terms of lower death, MI, and stroke as suggested by TIMACS trial [ 37 ] and ACUITY trial [ 38 ].…”

One‐year mortality in NSTEMI patients is unaffected by timing of PCI within the first week of admission: Results of a real‐world cohort analysis

“…However, this study included relatively low‐risk NSTE‐ACS patients with a mean GRACE‐risk of 122 17 . Also, a “real‐world” prospective registry by Badings et al (n = 2299) showed no improvement in mortality rate if an early strategy (<24 h) was compared to a delayed strategy (>24 h) 18 . Finally, a meta‐analysis by Jobs et al addressing the question of optimal timing of an invasive strategy in NSTE‐ACS analyzed eight trials (n = 5324) with a median follow‐up of 180 days (IQR 180–360).…”

Treatment strategies and outcomes in patients with non-ST-elevation acute coronary syndrome in the Netherlands

“…In the current issue of the Netherlands Heart Journal, Badings et al. describe the use, timing and outcome of coronary angiography in patients with high-risk NSTE-ACS in daily clinical practice in the Netherlands [ 12 ]. Consecutive ACS patients who presented at the Isala hospital in Zwolle are described.…”