Main Article Content
Acute coronary syndrome, Invasive, noninvasive.
Background and objectives: The term acute coronary syndrome (ACS) is a range of acute myocardial ischemic states including unstable angina (UA), non-ST segment (NSTE), and ST-segment elevation myocardial infarction (STEMI). It is required to identify the cardiovascular events risk in those patients in order to select the beneficial therapeutic strategy during the first hours of presentation. The aim of the present study is to stratify the cardiac event risk and to determine the clinical eligibility of invasive vs. noninvasive therapeutic strategy in patients presented with UA and NSEMI as defined as NSTE-ACS.
Methods: In the current observational cross-sectional study, 100 consecutive patients who visited the emergency department and admitted to coronary care unit diagnosed as NSTE-ACS were recruited. Their medical and clinical information were obtained from the patient and medical records. The cardiac event risk was estimated according to the GRACE risk score (Global Registry of Acute Coronary Events) and the TIMI risk score (Thrombolysis in Myocardial Infarction). The clinical eligibility of invasive vs. noninvasive (Ischemia-guided) therapeutic strategy was determined according to the latest AHA/ACC guideline for the management of patients with NSTE-ACS in 2014.
Results: Of patients presented with NSTE-ACS who underwent both therapeutic strategies most of them were males (71.0%). The mean ± S.D. was 60-62 years for age. The mean ± S.D. of body mass index (BMI), chest pain duration, systolic blood pressure and heart rate were comparable in two groups. In terms of clinical characteristics hypertension (72.0%), current smoking (56.0%), dyslipidemia (48.0%), and past history of coronary artery disease (CAD) (44.0%) were the most prevalent. Patients who underwent invasive strategy had significantly more ST-depression (75.6%) as compared to those who underwent non-invasive strategy (55.9%), P=0.044. However, non-invasive group had significantly more T-wave inversion, (59.3% vs. 34.1%; P=0.013). The studied groups showed no statistically significant difference in risk of mortality according to GRACE risk score (P=0.505), TIMI risk score (P=0.057), and Killip class (P=0.252). However, the majority of non-invasive group had low risk (67.8%) while, the invasive group more common to be at intermediate risk (29.3%) for 6-month mortality. There was no statistically significant predictor of two therapeutic strategies according to the patients characteristics and risk stratification (p>0.05).
Bhatt, D.L., Roe, M.T., Peterson, E.D., Li, Y., Chen, A.Y., Harrington, R.A., et al. 2004. Utilization of early invasive management strategies for high-risk patients with non–ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Jama, 292, 2096-2104.
Boersma, E., Pieper, K.S., Steyerberg, E.W., Wilcox, R.G., Chang, W.-C., Lee, K.L., et al. 2000. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation: results from an international trial of 9461 patients. Circulation, 101, 2557-2567.
Braunwald, E., Antman, E.M., Beasley, J.W., Califf, R.M., Cheitlin, M.D., Hochman, J.S., et al. 2002. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non–ST-segment elevation myocardial infarction—summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). Journal of the American College of Cardiology, 40, 1366-1374.
Chang, H., Min, J.K., Rao, S.V., Patel, M.R., Simonetti, O.P., Ambrosio, G., et al. 2012. Non–ST-Segment Elevation Acute Coronary Syndromes: Targeted Imaging to Refine Upstream Risk Stratification. Circulation: Cardiovascular Imaging, 5, 536-546.
Eagle, K.A., Goodman, S.G., Avezum, Á., Budaj, A., Sullivan, C.M., López-Sendón, J., et al. 2002. Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE). The Lancet, 359, 373-377.
Eagle, K.A., Lim, M.J., Dabbous, O.H., Pieper, K.S., Goldberg, R.J., Van de Werf, F., et al. 2004. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. Jama, 291, 2727-2733.
Fitchett, D.H., Borgundvaag, B., Cantor, W., Cohen, E., Dhingra, S., Fremes, S., et al. 2006. Non-ST segment elevation acute coronary syndromes: A simplified risk-oriented algorithm. Canadian Journal of Cardiology, 22, 663-677.
Fox, K.A., Goodman, S.G., Klein, W., Brieger, D., Steg, P.G., Dabbous, O., et al. 2002. Management of acute coronary syndromes. Variations in practice and outcome. Findings from the Global Registry of Acute Coronary Events (GRACE). European Heart Journal, 23, 1177-1189.
Goldstein, J.A., Demetriou, D., Grines, C.L., Pica, M., Shoukfeh, M. & O'neill, W.W. 2000. Multiple complex coronary plaques in patients with acute myocardial infarction. New England Journal of Medicine, 343, 915-922.
Grech, E.D. & Ramsdale, D.R. 2003. ABC of interventional cardiology: Acute coronary syndrome: unstable angina and non-ST segment elevation myocardial infarction. BMJ: British Medical Journal, 326, 1259.
Hoedemaker, N.P., Damman, P., Woudstra, P., Hirsch, A., Windhausen, F., Tijssen, J.G., et al. 2017. Early invasive versus selective strategy for non–ST-segment elevation acute coronary syndrome: the ICTUS trial. Journal of the American College of Cardiology, 69, 1883-1893.
Roffi, M., Patrono, C., Collet, J.-P., Mueller, C., Valgimigli, M., Andreotti, F., et al. 2016. 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). European heart journal, 37, 267-315.
Sanchez, P., Morinigo, J., Pabon, P., Martin, F., Piedra, I., Palacios, I., et al. 2004. Prognostic relations between inflammatory markers and mortality in diabetic patients with non-ST elevation acute coronary syndrome. Heart, 90, 264-269.
Steg, P.G., Goldberg, R.J., Gore, J.M., Fox, K.A., Eagle, K.A., Flather, M.D., et al. 2002. Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE). American Journal of Cardiology, 90, 358-363.
Tubaro, M., Sciahbasi, A., Ricci, R., Ciavolella, M., Di Clemente, D., Bisconti, C., et al. 2017. Early invasive versus early conservative strategy in non-ST-elevation acute coronary syndrome: an outcome research study. European Heart Journal: Acute Cardiovascular Care, 6, 477-489.
Zimmerman, J., Fromm, R., Meyer, D., Boudreaux, A., Wun, C.-C.C., Smalling, R., et al. 1999. Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Circulation, 99, 1671-1677.