scholarly journals Management and outcome of non-ST-elevation acute coronary syndromes in the elderly admitted to spoke hospitals with no cath-lab facility

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
F Mantovani ◽  
E Guerri ◽  
F Manca ◽  
M Calzolari ◽  
I Colaiori ◽  
...  
Keyword(s):  
Acute Coronary Syndromes ◽  
Invasive Procedure ◽  
The Elderly ◽  
Service Strategy ◽  
Conservative Strategy ◽  
Invasive Strategy ◽  
Funding Sources ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy

Abstract Background Current guidelines recommend an early invasive strategy in patients with non-ST-elevation acute coronary syndromes (NSTE-ACS). However, the role of an invasive strategy in elderly patients remains controversial and may be difficult to achieve in spoke hospitals with no cath-lab facility. Purpose We aimed to analyze characteristics and outcomes of patients ≥80 years with NSTE-ACS admitted to spoke hospitals. Methods Observational retrospective study of all consecutive NSTE-ACS patients admitted to two spoke hospitals, where a service strategy (same-day transfer between spoke hospital and hub center with a cath-lab facility to perform coronary angiography) was available. Results From 2013 to 2017, 639 patients were admitted for NSTE-ACS in a spoke hospital of our provincial cardiology network; of these, 181 (28%) were ≥80 years (median 84, IQR 82–89). In the elderly conservative strategy was chosen in 76 patients (42%). When the invasive strategy was chosen, 104 patients (93%) were managed with a Service strategy with no major adverse event observed during the back transfer from the invasive center to the referring spoke center, whereas the rest of the patients (8, 7%) were transferred from the spoke hospital to the hub center and completed their hospital stay without returning to the spoke center. Of patients initially managed with the service strategy, a shift of strategy after the invasive procedure was necessary for 11 (10%) and the patients remained in the hub center. The median time to access to cath-lab was 50 hours (IQR 25–87), with 73 patients (70%) reaching the invasive procedure <72 h from the hospital admission and 23 (22%) <24 h. Conservative strategy was associated with older age, known previous CAD, clinical presentation with symptoms of LV dysfunction, lower EF, renal failure, higher GRACE score, presence of PAD, and atrial fibrillation (all p<0.03; Table). At 1-year follow-up, the overall survival was significantly higher in patients treated with invasive strategy compared to patients managed conservatively (94%±2 vs. 54%±6, p<0.001; HR: 10.4 [4.7–27.5] p<0.001; Figure), even after adjustment for age, serum creatinine, known previous CAD and EF (adjusted HR: 2.0 [1.0–4.0]; p<0.001). Conclusion An invasive strategy may confer a survival benefits in the elderly with NSTE-ACS. When the invasive strategy is chosen, the same-day transfer between spoke hospital and hub center with the cath-lab facility (service strategy) is safe and granted the access to cath-lab in a timely fashion even in the elderly. FUNDunding Acknowledgement Type of funding sources: None. Table 1 Figure 1

Abstract 1801: The Benefit of an Early Invasive Strategy in Women Versus Men with Non-ST-Elevation Acute Coronary Syndromes: A Collaborative Meta-Analysis of Randomized Trials

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Michelle O’Donoghue ◽  
Marc S Sabatine ◽  
William E Boden ◽  
Eugene Braunwald ◽  
Christopher P Cannon ◽  
...  
Keyword(s):  
Acute Coronary Syndromes ◽  
Randomized Trials ◽  
Meta Analysis ◽  
Significant Coronary Artery Disease ◽  
Significant Heterogeneity ◽  
Conservative Strategy ◽  
Invasive Strategy ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy

Background: Although an early invasive strategy (INV) is frequently used in patients with non-ST-elevation acute coronary syndromes (NSTEACS), some trials have shown this strategy to be associated with worse outcomes in women. We conducted a collaborative meta-analysis of randomized trials of INV vs. conservative strategy (CONS) stratified by gender and biomarker (CK-MB or troponin) elevation. Methods : The principal investigators for each trial provided data on the incidence of death (D), non-fatal MI (MI) and rehospitalization with ACS by gender & biomarker elevation through long-term follow-up. Odds ratios from each trial were combined using a random-effects model with weighting based on inverse variance. Results: Data were combined across 8 trials (3075 women, 7074 men). The OR for D/MI/ACS for INV vs. CONS was 0.83 in women (95% CI 0.68–1.01) and 0.75 in men (95% CI 0.58 – 0.98) with no significant heterogeneity between genders (P=0.54). In women, the benefit of INV tended to be greater in those with elevated biomarkers (OR 0.73, 0.58 – 0.92), compared with those without (OR 0.99, 0.67–1.47) (P interaction=0.19). In contrast, men benefited from INV irrespective of biomarker status (OR 0.78, 0.57–1.07 and OR 0.75, 0.58 – 0.98, P interaction=0.85). For patients in the INV arms, women were more frequently found to have no significant coronary artery disease (stenosis diameter <50%) at angiography than were men (27% vs 8%, P<0.001). Conclusions: In patients with NSTEACS, an INV strategy reduces the composite of death, MI or rehospitalization with ACS to a similar extent in both women and men. Elevated biomarkers of necrosis may help identify women who benefit most from an INV strategy. Death, Non-fatal MI or Rehospitalization with ACS*

Routine Invasive Strategy Compared with a Selective Invasive Strategy in Women with Non-ST-elevation Acute Coronary Syndromes

2009 ◽  
Vol 5 (1) ◽  
pp. 81
Author(s):  
Joakim Alfredsson ◽  
Eva Swahn ◽  
◽  
Keyword(s):  
Gender Differences ◽  
Acute Coronary Syndromes ◽  
Heart Association ◽  
Invasive Treatment ◽  
Invasive Strategy ◽  
Class 1 ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy ◽  
European Society Of Cardiology

Cardiovascular disease is the leading cause of death in both men and women in the developed world. Non-ST-elevation acute coronary syndromes (NSTE-ACS) are the most prevalent acute manifestations of coronary heart disease. Revascularisation is performed in the NSTEACS setting to relieve symptoms and prevent progression to myocardial ischaemia and death. Today, early invasive treatment with coronary angiography and revascularisation if feasible has become the strategy of choice in patients with NSTE-ACS, and is a class 1 recommendation in both American College of Cardiology/American Heart Association (ACC/AHA) and European Society of Cardiology (ESC) guidelines on NSTE-ACS, at least for patients with medium- or high-risk indications. However, gender differences in terms of benefit from an early invasive strategy have been intensively debated and the data are conflicting. In this article, we will discuss possible gender differences in randomised trials addressing this matter.

Abstract 2804: Early Invasive Management of Acute Coronary Syndromes without ST-elevation: Relation between Rate of Invasive Therapies and Very Long-term Mortality in the Randomized Trials

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Freek W Verheugt ◽  
Marc A Brouwer
Keyword(s):  
Acute Coronary Syndromes ◽  
Randomized Trials ◽  
Conservative Strategy ◽  
Invasive Therapy ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy ◽  
Recurrent Ischemia ◽  
Long Term Mortality

Background Randomized trials evaluating an early invasive against a conservative strategy show a benefit over a conservative approach in the composite of death, MI and revascularisation/recurrent ischemia. However, the rate of invasive therapies differed significantly in the trials. Moreover, there were also large differences in the rate of invasive therapies in the invasive versus the conservative arms ( cross-over rate) in the different studies. Therefore we studied the differences in rate of invasive therapy in the study arms of the above trials, and correlated them with the benefit of the invasive therapy with regard to the very long-term mortality as recently published. Methods and Results We analyzed very long-term mortality (30,932 patient-years) in the 9 trials carried out between 1996 and 2004, which randomized 10,558 patients with non-ST-elevation acute coronary syndromes to an early invasive or an ischemia-guided conservative strategy. Differences in the revascularization rate between the invasive and conservative strategies in the trials ranged between 10% and 39%. There was no relation of the differences in revascularization between invasive and conservative strategies and the benefit on mortality whatsoever (see figure ). Conclusion Although most trials on non ST-elevation ACS reported a reduction in the composite of death, MI and revascularisation/ recurrent ischemia, an early invasive strategy does not lead to improved survival on the very long-term. There seems no relation between the difference in revascularisation rate and benefit on the very long term, which may explain the lack of efficacy of early intervention on very long-term mortality.

Abstract 3210: Early Invasive Management of Acute Coronary Syndromes without ST-elevation does not Improve Long-term Mortality: insights from the Randomized Trials with the most Recent Follow-up Data

Circulation ◽  
2007 ◽  
Vol 116 (suppl_16) ◽  
Author(s):  
Freek W Verheugt ◽  
Marc A Brouwer
Keyword(s):  
Acute Coronary Syndromes ◽  
Randomized Trials ◽  
Conservative Strategy ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy ◽  
Recurrent Ischemia ◽  
Long Term Mortality

Background Randomized trials evaluating an early invasive against a conservative strategy show a benefit over a conservative approach in the composite of death, MI and revascularisation/recurrent ischemia. However, by the necessarily open design MI and revascularisation/ recurrent ischemia are relatively weak endpoints. Since MI is both an entry criterion and an endpoint, it is difficult to evaluate, since it may be induced by intervention and, therefore, its definition in the trials is cumbersome. Thus, long-term mortality is the best outcome parameter to evaluate the above strategies. Recently, the very long follow-up data of 3 major trials RITA-3, FRISC-2 and ICTUS have been published. Methods and Results We analyzed the 9 trials carried out between 1996 and 2004, which randomized 10,558 patients with non-ST-elevation acute coronary syndromes to an early invasive or an ischemia-guided conservative strategy. F/U ranged from 6 months to 5 years with a total of 30,932 patients-years. RR for long-term mortality is for invasive versus conservative from completed follow-up data is 0.94 (95%CI 0.83–1.06, p = 0.32, see figure ). Conclusion Although most trials on non ST-elevation ACS reported a reduction in the composite of death, MI and revascularisation/recurrent ischemia, an early invasive strategy does not lead to improved survival on the very long-term. These findings should be mentioned in future guidelines.

scholarly journals Early invasive strategy in elderly patients with non-ST-elevation acute coronary syndromes

2005 ◽  
Vol 7 (suppl_K) ◽  
pp. K23-K25 ◽  
Author(s):  
Francesco Liistro ◽  
Kenneth Ducci ◽  
Giovanni Falsini ◽  
Leonardo Bolognese
Keyword(s):  
Elderly Patients ◽  
Acute Coronary Syndromes ◽  
Invasive Strategy ◽  
Coronary Syndromes ◽  
St Elevation ◽  
Early Invasive Strategy
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