Angiographic factors strongly predict ischemic outcomes in NSTE-ACS
MedWire News: Angiographic parameters are more powerfully predictive of ischemic outcomes than traditional clinical parameters in non-ST-segment elevation acute coronary syndrome (NSTE-ACS) patients treated medically, a substudy of ACUITY indicates.
This supports early use of angiographic screening in moderate- and high-risk ACS patients, say authors Alexandra Lansky (Columbia University, New York, USA) and colleagues.
The researchers studied 4491 ACS patients in ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) who were treated medically after angiographic triage. They first compared bleeding and composite ischemia (death, myocardial infarction, or revascularization) outcomes among the three antithrombotic treatment arms of the trial.
Patients who received bivalirudin with or without glycoprotein (GP) IIb/IIIa inhibitors had reduced major bleeding at 30 days compared with those who received heparin plus GP IIb/IIIa inhibitors (2.5% and 2.0% vs 4.4%, respectively, p<0.01 for both comparisons).
Composite ischemic events at 1 year did not differ significantly among the three groups, at 9.6%, 9.7%, and 9.1%, respectively.
In multivariable analysis, only the angiographic factors coronary ectasia and jeopardy score predicted short-term (30-day) composite ischemia, while mostly angiographic factors –jeopardy score, coronary ectasia, and number of diseased vessels – as well as previous percutaneous coronary intervention (PCI) predicted 1-year composite ischemia.
Further analysis demonstrated that addition of the number of diseased vessels to the TIMI (Thrombolysis in MI) risk score added significant prognostic value in patients with high (5–7) and intermediate (3–4) TIMI scores, with 1-year composite ischemia outcomes for those with 0, 1–2, and 3 diseased vessels of 3.1%, 7.6%, and 14.1% and 4.3%, 10.4%, and 15.9%, respectively.
This underscores “the importance of angiographic screening among moderate- and high-risk patients with ACS even when destined for medical therapy as defined by this ACUITY subgroup,” say the authors.
In a related editorial, David Hasdai (Tel Aviv University, Israel) pointed out that, given only two out of three intermediate- to high-risk NSTE-ACS patients underwent revascularization on the basis of the coronary angiography findings, “it may be prudent to obtain angiographic data noninvasively, sparing patients with inherent complications of invasive procedures.”
An attractive alternative is multidetector computed tomography of the coronary arteries, he added.
In the meantime, Hasdai recommended shortening the time from diagnosis to angiography, imaging in the safest manner by the radial approach, and considering more potent antithrombotic regimens primary for patients undergoing PCI, preferably on an ad-hoc basis.
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By Caroline Price