Abstract 12774: Medical Management of Patients with Non-ST-Segment Elevation Acute Coronary Syndromes Following Coronary Angiography Showing Significant Obstructive Coronary Lesions: Insights from the EARLY ACS Trial
Background: US and European practice guidelines endorse early angiography for high-risk non-ST elevation acute coronary syndrome (NSTE ACS) patients (pts) followed by either anatomy-driven revascularization or conservative medical management (med mgmt). Factors associated with med mgmt in NSTE ACS pts with obstructive coronary disease (CAD) documented by angiography are not well characterized.
Methods: We examined pt factors and regional variation in the selection of med mgmt after angiography in high-risk NSTE ACS pts (older age, positive cardiac markers, and/or ischemic ECG changes) enrolled in the EARLY ACS trial, conducted in 29 countries from 2004–2008. Pts had significant CAD (>=1 lesion >50% in a major epicardial artery). Multivariable logistic regression analyses assessed relationships of baseline clinical factors (up to and including angiographic findings) and region with med mgmt.
Results: Of 9406 pts, 8387 (89%) underwent angiography and had significant CAD; 1766 (21%) were treated with med mgmt alone, 5445 (65%) had percutaneous coronary intervention, and 1176 (14%) had bypass surgery (CABG). Med mgmt alone was used in 22.6% of pts in North America, 20.2% in Western Europe, 18.4% in Eastern Europe, and 22.0% in Middle East/Africa/Asia-Pacific (distribution p value = 0.02). These pts were older, more often female and diabetic, less often had elevated baseline troponin (Tn) or ischemic ECG changes, and more often had prior MI or CABG. In a multivariable model, factors most strongly associated with med mgmt were: normal baseline Tn value, prior CABG, shorter time from randomization to angiography, greater number of diseased vessels, lack of ischemic ECG changes, lower body weight, and lower baseline hemoglobin. Region was not associated with med mgmt. Model c-index was 0.69.
Conclusions: About 20% of high-risk NSTE ACS pts with significant CAD in an international trial were treated with med mgmt alone after angiography, with only slight regional heterogeneity. Clinical factors predicted med mgmt only modestly well. A better understanding of the factors driving selection of med mgmt alone in these pts and the implications for clinical outcomes is needed.
- © 2010 by American Heart Association, Inc.