Background: The role of revascularization with percutaneous coronary intervention (PCI) in the management of Unstable Angina and Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) remains controversial. Previous post hoc analysis of randomized clinical trials has shown that troponin elevation permits the determination of high-risk patients who may benefit more from PCI. We further explored this hypothesis in clinical practice, attempting to address previous concerns on baseline risk of patients as assessed by biomarker status (UA versus NSTEMI). Methods: The study population of the present analysis consists of the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC/NCT01218776) registry participants. This is an observational study of 1940 UA/NSTEMI patients; of these 805 underwent routine PCI and 1135 received medical therapy (MT) alone. The primary outcome was all-cause in-hospital mortality. Results: Patients treated with MT alone included a greater number of females (37% versus 26.21%, p<0.001), had higher rates of cerebrovascular disease (7.22% versus 3.11%, p=0.0001), of diabetes (30.6% versus 21.53%, p<0.001) and Killip class ≥ 2 (21.10% versus 17.07%, p=0.1759), but lower rates of smoking (24.55% versus 40.30%, p<0.001) and hypercholesterolemia (42.76% versus 46.41%, p=0.1466) than their counterpart undergoing PCI. In multivariable regression analysis, in-hospital revascularization was independently associated with a reduction of the primary outcome when compared with MT: adjusted odd ratio (OR) 0.37 (95% confidence interval [CI]: 0.19–0.72, p=0.003] and 3.24 (95%CI 1.44 – 7.30, p=0.004). Analysis restricted to patients with NSTEMI showed attenuation in the effect size for all-cause mortality: adjusted OR: 0.49 ; 95% CI: 0.25–0.96, p=0.037 and 2.32 (95% CI: 1.02 – 5.29, p=0.045). Conclusions: Contrary to expectations, a routine strategy with PCI was associated with greater benefits in patients with negative troponin status ( UA). Potential clinical benefits from PCI do not seem to favorably affect the overall prognosis of the index myocardial infarction (NSTEMI). Larger randomized studies are required to prove this conclusively.
Edina Cenko, Beatrice Ricci, Olivia Manfrini, Maria Dorobantu, Zorana Vasiljevic, Bozidarka Knezevic, et al. (2014). ROUTINE PERCUTANEOUS CORONARY INTERVENTION VERSUS MEDICAL THERAPY IN CLINICAL PRACTICE: THE ISACS-TC REGISTRY. JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 63(12_S), A214-A214 [10.1016/S0735-1097(14)60214-X].
ROUTINE PERCUTANEOUS CORONARY INTERVENTION VERSUS MEDICAL THERAPY IN CLINICAL PRACTICE: THE ISACS-TC REGISTRY
CENKO, EDINA;RICCI, BEATRICE;MANFRINI, OLIVIA;BUGIARDINI, RAFFAELE
2014
Abstract
Background: The role of revascularization with percutaneous coronary intervention (PCI) in the management of Unstable Angina and Non-ST-Elevation Myocardial Infarction (UA/NSTEMI) remains controversial. Previous post hoc analysis of randomized clinical trials has shown that troponin elevation permits the determination of high-risk patients who may benefit more from PCI. We further explored this hypothesis in clinical practice, attempting to address previous concerns on baseline risk of patients as assessed by biomarker status (UA versus NSTEMI). Methods: The study population of the present analysis consists of the International Survey of Acute Coronary Syndromes in Transitional Countries (ISACS-TC/NCT01218776) registry participants. This is an observational study of 1940 UA/NSTEMI patients; of these 805 underwent routine PCI and 1135 received medical therapy (MT) alone. The primary outcome was all-cause in-hospital mortality. Results: Patients treated with MT alone included a greater number of females (37% versus 26.21%, p<0.001), had higher rates of cerebrovascular disease (7.22% versus 3.11%, p=0.0001), of diabetes (30.6% versus 21.53%, p<0.001) and Killip class ≥ 2 (21.10% versus 17.07%, p=0.1759), but lower rates of smoking (24.55% versus 40.30%, p<0.001) and hypercholesterolemia (42.76% versus 46.41%, p=0.1466) than their counterpart undergoing PCI. In multivariable regression analysis, in-hospital revascularization was independently associated with a reduction of the primary outcome when compared with MT: adjusted odd ratio (OR) 0.37 (95% confidence interval [CI]: 0.19–0.72, p=0.003] and 3.24 (95%CI 1.44 – 7.30, p=0.004). Analysis restricted to patients with NSTEMI showed attenuation in the effect size for all-cause mortality: adjusted OR: 0.49 ; 95% CI: 0.25–0.96, p=0.037 and 2.32 (95% CI: 1.02 – 5.29, p=0.045). Conclusions: Contrary to expectations, a routine strategy with PCI was associated with greater benefits in patients with negative troponin status ( UA). Potential clinical benefits from PCI do not seem to favorably affect the overall prognosis of the index myocardial infarction (NSTEMI). Larger randomized studies are required to prove this conclusively.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
