A decisão de não revascularizar o enfarte agudo do miocárdio sem supradesnivelamento de ST – condicionantes e prognóstico. A realidade nacional

Multivessel vs. culprit-only revascularization in patients with non-ST-elevation acute coronary syndromes and multivessel coronary disease

INTRODUCTION

There have been no prospective randomized trials that enable the best strategy and timing to be determined for revascularization in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and multivessel coronary artery disease (CAD).

OBJECTIVES

To compare short- and long-term adverse events following multivessel vs. culprit-only revascularization in patients with NSTE-ACS and multivessel CAD.

METHODS

This was a retrospective observational study that included all patients diagnosed with NSTE-ACS and multivessel CAD who underwent percutaneous coronary intervention (PCI) between January 2010 and June 2013 (n=232). After exclusion of patients with previous coronary artery bypass grafting (n=30), a multivessel revascularization strategy was adopted in 35.1% of patients (n=71); in the others (n=131, 64.9%), only the culprit artery was revascularized. After propensity score matching (PSM), two groups of 66 patients were obtained, matched according to revascularization strategy.

RESULTS

During follow-up (1543±545 days), after PSM, patients undergoing multivessel revascularization had lower rates of reinfarction (4.5% vs. 16.7%; log-rank p=0.018), unplanned revascularization (6.1% vs. 16.7%; log-rank p=0.048), unplanned PCI (3.0% vs. 13.6%; log-rank p=0.023) and the combined endpoint of death, reinfarction and unplanned revascularization (16.7 vs. 31.8%; log-rank p=0.046).

CONCLUSIONS

In real-world patients presenting with NSTE-ACS and multivessel CAD, a multivessel revascularization strategy was associated with lower rates of reinfarction, unplanned revascularization and unplanned PCI, as well as a reduction in the combined endpoint of death, reinfarction and unplanned revascularization.

Sex-related inequalities in management of patients with acute coronary syndrome-results from the EURHOBOP study

BACKGROUND

Real-world data from different levels of hospital specialisation would help to understand if differences in management between women and men with acute coronary syndrome (ACS) are still a priority target. We aimed to identify sex inequalities in management of patients with different types of ACS.

METHODS

We analysed 1757 patients with a non-ST-elevation ACS (NSTEACS) and 1184 with ST elevation myocardial infarction (STEMI) or left bundle branch block (non-classifiable (NC) ACS (STEMI/NC ACS group), consecutively discharged from ten Portuguese hospitals with different specialisation levels, between 2008 and 2010. We estimated odds ratios (OR) and 95% confidence intervals (95% CI) for the association between sex and the performance of coronary angiography, reperfusion and revascularisation.

RESULTS

Among STEMI/NC ACS, men had higher probability of performing coronary angiography than women (adjusted OR = 1.64, 95% CI: 1.11-2.44), while among NSTEACS patients there was no significant difference by sex (adjusted OR = 1.26, 95% CI: 0.99-1.62). In patients who underwent coronary angiography, there was no difference in proportion of women and men submitted to revascularisation, regardless of the ACS type. Although men with STEMI/NC ACS were more likely to undergo reperfusion (crude OR = 2.17, 95% CI: 1.68-2.81), the effect became not significant after multivariable adjustment (adjusted OR = 1.33, 95% CI: 0.96-1.84).

CONCLUSION

Women diagnosed with STEMI/NC, but not NSTEACS, had lower probability when compared with men to be submitted to coronary angiography. There was no difference in performance of reperfusion and revascularisation by sex.

ProACS risk score: An early and simple score for risk stratification of patients with acute coronary syndromes

INTRODUCTION

There are barriers to proper implementation of risk stratification scores in patients with acute coronary syndromes (ACS), including their complexity. Our objective was to develop a simple score for risk stratification of all-cause in-hospital mortality in a population of patients with ACS.

METHODS

The score was developed from a nationwide ACS registry. The development and internal validation cohorts were obtained from the first 31829 patients, randomly separated (60% and 40%, respectively). The external validation cohort consisted of the last 8586 patients included in the registry. This cohort is significantly different from the other cohorts in terms of baseline characteristics, treatment and mortality. Multivariate logistic regression analysis was used to select four variables with the highest predictive potential. A score was allocated to each parameter based on the regression coefficient of each variable in the logistic regression model: 1 point for systolic blood pressure ≤116 mmHg, Killip class 2 or 3, and ST-segment elevation; 2 points for age ≥72 years; and 3 points for Killip class 4.

RESULTS

The new score had good discriminative ability in the development cohort (area under the curve [AUC] 0.796), and it was similar in the internal validation cohort (AUC 0.785, p=0.333). In the external validation cohort, there was also excellent discriminative ability (AUC 0.815), with an adequate fit.

CONCLUSIONS

The ProACS risk score enables easy and simple risk stratification of patients with ACS for in-hospital mortality that can be used at the first medical contact, with excellent predictive ability in a contemporary population.