Prognostic differences between routine invasive and conservative strategies for the management of high-risk, non-ST segment acute coronary syndromes: Experience from two consecutive periods in a single center

Núñez, Julio; Sanchis, Juan; Núñez, Eduardo; Bodi, Vicent; Bertomeu-González, Vicente; Bosch, Maria J.; Santas, Enrique; Fácila, Lorenzo; Chorro, Francisco J.; Gómez, Cristina; Consuegra, Luciano; Llàcer, Angel

doi:10.1016/j.ejim.2006.12.011

« Previous Next »European Journal of Internal Medicine
Volume 18, Issue 5 , Pages 409-416, September 2007

Prognostic differences between routine invasive and conservative strategies for the management of high-risk, non-ST segment acute coronary syndromes: Experience from two consecutive periods in a single center☆

Servicio de Cardiología, Hospital Clínico Universitario, Universitat de Valencia, Valencia, Spain

Received 5 June 2006; received in revised form 6 November 2006; accepted 15 December 2006. published online 09 July 2007.

Abstract

Background

The optimal revascularization strategy for non-ST elevation acute coronary syndromes (NSTE-ACS) remains controversial, especially in a real world context. The objective of this work was to assess differences at 1 year in all-cause mortality and the composite endpoint of mortality or acute myocardial infarction (MI) between two management strategies for NSTE-ACS: a conservative strategy (CS) versus a routine invasive strategy (RIS).

Methods

Of 799 consecutive patients admitted to our institution, 369 were treated with CS (from January 2001 to October 2002); 430 patients admitted with the same diagnosis were treated with RIS (from November 2002 to November 2004). A propensity score (PS) matched sample was created and included 694 patients (87% of the original population). The event rate was compared between each paired member of the PS-matched sample, one receiving RIS and the other CS, and their differences were tested by Cox proportional analysis.

Results

No significant differences in baseline characteristics were noted between the two management cohorts. By design, the rate of in-hospital catheterization and revascularization procedures increased in RIS compared with CS. The mortality rate was lower, but not significant, in RIS (HR: 0.76, 95% CI=0.51–1.11; p=0.155). For the composite of death or MI, RIS showed a relative risk reduction of 29% (HR: 0.71, 95% CI=0.53–0.94); p=0.018) compared with CS, differences that become non-significant (p=0.680) if we adjust for differences in rate of revascularization procedures and changes in medication prescription.

Conclusions

RIS was associated with a 1-year lower risk of the combined endpoint of all-cause death and MI in patients with NSTE-ACS, attributable to changes in frequency of revascularization procedures and in medical treatment.

Keywords: Non-ST elevation acute coronary syndromes, Prognosis, Invasive strategy, Conservative strategy