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Timing of angiography/revascularization for non-STE ACS does not affect outcomes

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – For patients with non-ST-segment elevation acute coronary syndrome (nSTE-ACS), long-term outcomes are no different whether they undergo angiography, and revascularization if indicated, within 2 days or after 3-5 days.

That finding, derived from a pooled database of three trials, is reported in the February issue of JACC: Cardiovascular Interventions, by Dr. Robbert J. de Winter, at the Academic Medical Center, University of Amsterdam, the Netherlands, and colleagues.

“Keeping limitations of a post hoc analysis in mind,” they caution, “these findings should be interpreted as hypothesis-generating.”

They explain that the timing of angiography in nSTE-ACS patients is controversial. Early evaluation could expedite CABG or PCI in appropriate cases, but deferred angiography with intensive antithrombotic and anti-ischemic therapy might prevent procedure-related adverse events.

To look into the issue, the team performed a collaborative analysis of data from the FRISC-II, ICTUS and RITA-3 trials (collectively referred to as FIR) to determine 5-year rates of cardiovascular death or MI in 2721 patients originally randomized to routine angiography and subsequent revascularization if necessary.

In this cohort, 975 patients underwent early angiography and 1141 delayed angiography. The rate of the 5-year composite endpoint of death/MI in the two groups was 15.4% versus 14.8%, respectively.

This translated to an unadjusted hazard ratio of 1.06 (p=0.61). After adjustment for FIR risk score, the hazard ratio was 0.93 (p=0.54), the team found.

Discussing the clinical implications, Dr. de Winter and colleagues comment: “Because we did not observe a relation between timing of angiography and outcomes, a potential implication could be that angiography can be postponed to the next working day in patients presenting outside working hours. On the other side, early angiography might potentially reduce hospitalization time and associated costs.”

That said, and given the limitations of the analysis, they conclude, “Future research should focus on the patients at highest baseline risk and cost-effectiveness analyses.”


Timing of Angiography With a Routine Invasive Strategy and Long-Term Outcomes in Non–ST-Segment Elevation Acute Coronary Syndrome : A Collaborative Analysis of Individual Patient Data From the FRISC II (Fragmin and Fast Revascularization During Instability in Coronary Artery Disease), ICTUS (Invasive Versus Conservative Treatment in Unstable Coronary Syndromes), and RITA-3 (Intervention Versus Conservative Treatment Strategy in Patients With Unstable Angina or Non-ST Elevation Myocardial Infarction) Trials

JACC: Cardiovascular Interventions, 2012;5:191–199.