The effect of early invasive strategy on mortality outcome in patients with chronic kidney disease presenting with non-ST segment elevation myocardial infarction

Background Current guidelines recommend an early invasive strategy for patients with non-ST segment elevation myocardial infarction (NSTEMI). Purpose To evaluate whether early invasive strategy is associated with better outcome among patients with chronic kidney disease (CKD). Methods Retrospective cohort analysis of consecutive patients with NSTEMI between 2008 and 2021. Glomerular filtration rate (eGFR) was estimated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation. Invasively treated patients were dichotomized into early (<24 hours) and non-early groups. Mortality data was available for all patients from a national registry. Multivariate Cox regression models with interaction analysis were applied. Results Final study population comprised 7,107 NSTEMI patients, of whom 3,172 (45%) had eGFR <60 ml/min/1.73m2. 1,988 (28%) and 973 (14%) patients had eGFR under 45 and 30 ml/min/1.73m2, respectively. 3,529 (50%) patients were treated invasively, among them 1837 (52%) underwent early invasive strategy. Patients in the early invasive group were younger (64 vs. 68 years, p<0.001) and were less likely to have comorbidities including kidney disease. During a median follow-up of 3 years (IQR 1.2–5.2), 2,552 (36%) patients died. Kaplan Meier survival analysis demonstrated that the cumulative probability of death was 50%, 15%, and 6% among patients in the conservative, non-early, and early invasive groups respectively (p Log-rank <0.001). Subgroup analysis of invasively managed patients showed that early invasive strategy was associated with a significant 32% reduced risk of death in a multivariate model (95% CI 0.56–0.82, p<0.001), but this associated benefit was modified by eGFR (p for interaction 0.045). The modification effect of CKD on the association of early invasive strategy with outcome was most pronounced among invasively treated patients with eGFR <45 ml/min/1.73m2, with no survival benefit for early invasive approach in these patients (HR 0.8, 95% CI 0.57–1.14, p=0.221 vs. HR 0.6 95% CI 0.45–0.72, p<0.001; p for interaction=0.046). Conclusion Among invasively treated NSTEMI patients, the benefit of early invasive strategy is modified by CKD, and limited to those with eGFR ≥45 ml/min/1.73m2. FUNDunding Acknowledgement Type of funding sources: None.

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

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 13343: Is the Early Invasive Strategy Really the Optimal Time for Patients at High-risk of Acute Coronary Syndromes Without ST-segment Elevation?

Introduction: An early invasive strategy has become the standard of care for pts at high-risk of NSTE-ACS in the latest guidelines, however the optimal timing of coronary intervention in this pts is still a matter of debate. Hypothesis: To compare the prognosis between pts at high-risk of NSTE-ACS submitted an early (<24h) versus a delayed invasive strategy (24-72h). Methods: A retrospective multicenter observational study including 6722 pts at high-risk NSTE-ACS (established diagnosis of NSTE-ACS based on cardiac troponins OR dynamic ST/T-changes OR GRACE score>140). Low, intermediate and very high-risk of NSTE-ACS pts were excluded, such as pts with an invasive strategy >72h. Pts were divided into two groups: group 1 - pts at high-risk of NSTE-ACS submitted an early invasive strategy (<24h) (n=3351,49.9%); group 2 - pts at high-risk of NSTE-ACS submitted a delayed invasive strategy (24-72h) (n=3371,50.1%). Primary endpoint was the occurrence of death at 1 year. Results: The sample was formed by 74.5% men and 25.5% women, with mean age of 65±12 years. Group 2 pts had a higher prevalence of hypertension (69.4% vs 73.0%,p=0.001), dyslipidaemia (63.1% vs 66.7%,p=0.002), CKD (3.2% vs 4.9%,p<0.001), previous MI (19.9% vs 24.3%, p<0.001) and HF (2.4% vs 3.4%, p=0.012). On admission, group 1 pts had more chest pain (96.9% vs 95.7%, p=0.010) compared to group 2 pts that had more dyspnea (1.1% vs 1.9%,p=0.007) and presented more to a non-PCI center (36.0% vs 46.3%,p<0.001). During hospitalization, group 2 had more often HF (3.3% vs 4.5%,p=0.013) and LVEF≤40% (5.9% vs 7.6%,p=0.042). Group 1 pts were more likely to have coronary revascularization (78.9% vs 74.6%,p<0.001), with the culprit artery being less identified in group 2 (20.8% vs 25.2%,p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts at high-risk of NSTE-ACS submitted an early strategy had the same risk of 1-year mortality compared to those submitted a delayed invasive strategy [OR0.76,p=0.280]. Conclusion: In Portugal, only half of patients at high risk of NSTE-ACS undergo an early invasive strategy. However the early invasive coronary evaluation did not improve overall long-term clinical outcome compared with delayed invasive strategy.

Abstract 17267: Outcomes of Patients With Non-ST-Segment Elevation Myocardial Infarction and High Degree Atrioventricular Block Treated With Early vs Delayed Invasive Strategy

Introduction: High degree atrioventricular block (HDAVB) is an uncommon complication of non-ST-segment elevation myocardial infarction (NSTEMI), frequently necessitating pacemaker implantation. Hypothesis: This contemporary analysis compares the need for pacemaker implantation based on the timing of intervention in acute NSTEMI complicated by HDAVB. Methods: We used 2016-2017 National Inpatient Sample (NIS) database to identify all admissions with NSTEMI. Those without HDAVB were excluded from the study. Time to coronary intervention from initial admission was used to segregate the admissions into two groups: early invasive strategy (EIS) (<24 hours) and delayed invasive strategy (DIS)(>24 hours). A multivariate logistic and linear regression analysis was performed to compare in-hospital outcomes among both groups. Results: Out of 949,984 NSTEMI related admissions, coexistent HDAVB was present in 0.7% (n=6725) patients which were subsequently included in the study. Amongst those, 55.61% (n=3740) hospitalization included invasive intervention (EIS=1320, DIS=2420) (Figure1). Patients treated with EIS were younger (69.95 vs 72.38, p= <0.05) and had a concomitant cardiogenic shock. Contrarily the prevalence of chronic kidney disease (CKD), heart failure (HF), and pulmonary hypertension was higher in DIS group. EIS was associated with lower length of stay and total hospitalization cost. Although statistical significance was not achieved, a trend towards higher in-hospital mortality and lower pacemaker implantation rates were seen in hospitalizations involving EIS (Table1). Conclusions: HDAVB is a rare complication of NSTEMI and it is associated with significant mortality. The timing of revascularization does not appear to influence the rate of pacemaker placement in NSTEMI complicated by HDAVB. Further studies are needed to assess if all patients presenting with HDAVB should be treated with an early invasive strategy.

Outcomes in non-ST-segment elevation myocardial infarction patients according to heart failure at admission: Insights from a large trial with systematic early invasive strategy

Background Previous studies published before the era of systematic early invasive strategy have reported a higher mortality in non-ST-segment elevation myocardial infarction patients with heart failure. The aim of our study was to compare the clinical characteristics, outcomes and causes of death of patients according to their heart failure status at admission in a large non-ST-segment elevation myocardial infarction population with planned early invasive management. Methods We performed a post-hoc analysis of the Treatment of Acute Coronary Syndrome with Otamixaban randomised trial which included non-ST-segment elevation myocardial infarction patients with systematic coronary angiography within 72 h. Patients were categorised according to presence or absence of heart failure (Killip grade ≥2) at admission. Results A total of 13,172 patients were enrolled, of whom 944 (7.2%) had heart failure. At day 30, death occurred in 213 patients (1.6%) and cardiovascular death was the dominant cause of death in both groups ((with vs without heart failure) 78.8% vs 78.4%, p = 0.94). At six months, death occurred in 90/944 (9.5%) patients with heart failure and 258/12228 patients without heart failure (2.1%) ( p < 0.001). After adjustment on Global Registry of Acute Coronary Events risk score, heart failure was an independent predictor of all-cause mortality at day 30 (odds ratio: 1.58; 95% confidence interval, 1.06–2.36, p = 0.02) and at day 180 (odds ratio: 1.77; 95% confidence interval, 1.3–2.42, p < 0.001) as well as of ischaemic complications (cardiovascular death, myocardial infarction, stent thrombosis or stroke at day 30 (odds ratio: 1.28; 95% confidence interval, 1.01–1.62, p = 0.04). Conclusion Non-ST-segment elevation myocardial infarction patients with heart failure at admission still have worse outcomes than those without heart failure, even with systematic early invasive strategy. Further efforts are needed to improve the prognosis of these high risk patients.