This summary discusses the early invasive strategy and the risk of mortality in non-ST-elevation AMI.
Over the past 2 decades, mortality and complications rates have seen a significant reduction thanks to technological and pharmaceutical development, and the increasing experience of health teams. This is especially true when we look at the use of coronary angiography withing 72 hours of symptom onset; in these cases, mortality risk has gone from 3 to 6 months.
At present, the information is contradicting when it comes to an early invasive strategy. Even though some registries and randomized studies have not shown improvement, this might be the result of different factors, such as the time between symptom onset and the coronary angiography.
The KAMIR-NIH with 5856 non-ST myocardial infarction patients (NSTEMI) was analyzed: 3919 of these patients had a symptom onset to catheter time (StC) of <48 hours (66.9%) and 1937 a >48-hr StC.
Primary end point was all cause mortality at 3 years and secondary end point was the composite of all cause death, repeat MI or rehospitalization for cardiac failure at 3 years.
Mean age was 64 and over 70% were men.
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Patients presenting <48 hr. StC more often presented hypertension, diabetes, kidney function deterioration, MI, typical angina, angina after the first episode, less cardiac failure, lower GRACE score and better left ventricular function.
StC was 17.5 hrs. vs 90.8 hrs.
The presence of left main severe stenosis was 5.6%, 3 vessel disease 19%, 2 vessel lesion 28% and one vessel lesion 45%. PCI was done in 85% of cases, CABG in 1.5% and the rest received optimal medical treatment.
Primary end point at 3 years was 7.3% vs. 13.4% (3-year adjusted HR: 0.76; 95% CI:0.64-0.91; P = 0.002) for <48 hr. StC patient vs >48 hr StC patients respectively. Secondary end point was also in favor of <48 hr StC (12.2% vs. 19.6% 3-year adjusted HR: 0.84; 95% CI: 0.73-0.96; P=0.015).
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The use of emergency systems was associated to <48 hr StC and lower mortality.
Conclusion
An early invasive strategy based on symptom to catheter time was associated to lower all-cause mortality risk in NSTEMI patients. Seeing as this is a prospective registry, this conclusion should be considered as hypothesis generator to encourage future research.
Dr. Carlos Fava.
Member of the Editorial Board of SOLACI.org.
Original Title: Early Invasive Strategy Based on the Time of Symptom Onset of Non-ST-Segment Elevation Myocardial Infarction.
Reference: SungA Bae, et al. J Am Coll Cardiol Intv 2023;16:64–75.
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