Routine invasive strategies compared with conservative strategies do not lower the all-cause mortality in patients with non-ST elevation myocardial infarction and unstable angina

Abstract Objective Assess the incidence and compare characteristics and outcome of unstable angina (UA) and Non-ST-Elevation myocardial infarction (NSTEMI) Design Two independent prospective multicenter diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation (APACE) and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome (High-STEACS)) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30-days and 1-year. Results 8992 patients were enrolled at 11 centres. UA was adjudicated in 366/4122 (8.9%) and 137/4870 (2.8%) patients in APACE and High-STEACS, respectively, and NSTEMI in 622 (15.1%) and 651 (13.4%). Coronary artery disease was pre-existing in 73% and 76% of patients with unstable angina. At 30-days, all-cause mortality in UA was substantially lower as compared to NSTEMI (0.5% versus 3.7%, p=0.002 in APACE, 0.7% versus 7.4%, p=0.004 in High-STEACS). Similarly, at 1-year in UA all-cause mortality was 3.3% [95% CI 1.2–5.3] vs 10.4% [7.9–12.9] in APACE, and 5.1% [0.7–9.5] vs 22.9% [19.3–26.4] in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, [7.8–14.6] and 7.9%, [5.7–10.2]), and higher than in NCCP (0.6%, [0.2–1.0]). 1-year survival free from future AMI Conclusions The incidence and the mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar. Acknowledgement/Funding Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation Basel, British Heart Foundation Project Grants, Butler S

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Incidence and outcomes of unstable angina compared with non-ST-elevation myocardial infarction

Heart ◽

10.1136/heartjnl-2018-314305 ◽

2019 ◽

Vol 105 (18) ◽

pp. 1423-1431 ◽

Cited By ~ 10

Author(s):

Christian Puelacher ◽

Mathias Gugala ◽

Philip D Adamson ◽

Anoop Shah ◽

Andrew R Chapman ◽

...

Keyword(s):

Myocardial Infarction ◽

Unstable Angina ◽

High Sensitivity ◽

Final Diagnosis ◽

St Elevation Myocardial Infarction ◽

Coronary Syndrome ◽

Relative Incidence ◽

Incidence And Mortality ◽

All Cause Mortality ◽

St Elevation

ObjectiveAssess the relative incidence and compare characteristics and outcome of unstable angina (UA) and non-ST-elevation myocardial infarction (NSTEMI).DesignTwo independent prospective multicentre diagnostic studies (Advantageous Predictors of Acute Coronary Syndromes Evaluation [APACE] and High-Sensitivity Troponin in the Evaluation of Patients With Acute Coronary Syndrome [High-STEACS]) enrolling patients with acute chest discomfort presenting to the emergency department. Central adjudication of the final diagnosis was done by two independent cardiologists using all clinical information including serial measurements of high-sensitivity cardiac troponin (hs-cTn). All-cause death and future non-fatal MI were assessed at 30 days and 1 year.Results8992 patients were enrolled at 11 centres. UA was adjudicated in 8.9%(95% CI 8.0 to 9.7) and 2.8% (95% CI 2.3 to 3.3) patients in APACE and High-STEACS, respectively, and NSTEMI in 15.1% (95% CI 14.0 to 16.2) and 13.4% (95% CI 12.4 to 14.3). Coronary artery disease was pre-existing in 73% and 76% of patients with UA. At 30 days, all-cause mortality in UA was substantially lower as compared with NSTEMI (0.5% vs 3.7%, p=0.002 in APACE, 0.7% vs 7.4%, p=0.004 in High-STEACS). Similarly, at 1 year in UA all-cause mortality was 3.3% (95% CI 1.2 to 5.3) vs 10.4% (95% CI 7.9 to 12.9) in APACE, and 5.1% (95% CI 0.7 to 9.5) vs 22.9% (95% CI 19.3 to 26.4) in High-STEACS, and similar to non-cardiac chest pain (NCCP). In contrast, future non-fatal MI in APACE was comparable in UA and NSTEMI (11.2%, 95% CI 7.8 to 14.6 and 7.9%, 95% CI 5.7 to 10.2), and higher than in NCCP (0.6%, 95% CI 0.2 to 1.0).ConclusionsThe relative incidence and mortality of UA is substantially lower than that of NSTEMI, while the rate of future non-fatal MI is similar.

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