Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularization
Center for Outcomes Research; Department of Medicine, Division of Cardiovascular Medicine
Medical Subject Headings
Acute Coronary Syndrome; Age Factors; Aged; Angioplasty, Balloon, Coronary; *Cause of Death; Confidence Intervals; Coronary Angiography; Coronary Artery Bypass; Coronary Stenosis; Electrocardiography; Female; Heart Catheterization; Humans; Male; Middle Aged; Myocardial Infarction; Myocardial Revascularization; Odds Ratio; Ontario; Probability; Prognosis; Registries; Retrospective Studies; Risk Assessment; Severity of Illness Index; Sex Factors; Survival Analysis
Health Services Research
BACKGROUND: Contemporary guidelines support an early invasive strategy for non-ST elevation acute coronary syndrome (NSTE-ACS) patients who had prior coronary revascularization. However, little is known about the management pattern of these patients in "real world."
METHODS: We analyzed 3 consecutive Canadian registries (ACS I, ACS II, and Global Registry of Acute Coronary Events [GRACE]/expanded-GRACE) that recruited 12,483 NSTE-ACS patients from June 1999 to December 2007. We stratified the study population according to prior coronary revascularization status into 4 groups and compared their clinical characteristics, in-hospital use of medications, and cardiac procedures.
RESULTS: Of the 12,483 NSTE-ACS patients, 71.2% had no prior revascularization, 14.2% had percutaneous coronary intervention (PCI) only, 9.5% had coronary artery bypass graft surgery (CABG) only, and 5% had both PCI and CABG. Compared to their counterparts without prior revascularization, patients with previous PCI and/or CABG were more likely to be male, to have diabetes, myocardial infarction, and heart failure but less likely to have ST-segment deviation or positive cardiac biomarker on presentation. Early use of evidence-based medications was higher among patients with previous PCI only and lower among patients with previous CABG only. After adjusting for possible confounders including GRACE risk score, prior PCI was independently associated with in-hospital use of cardiac catheterization (adjusted odds ratio [OR] 1.18, 95% CI 1.04-1.34, P = .008). In contrast, previous CABG was an independent negative predictor (adjusted OR .77, 95% CI 0.68-0.87, P < .001). There was no significant interaction (P = .93) between previous PCI and CABG.
CONCLUSIONS: The NSTE-ACS patients with previous PCI were more likely to be treated invasively. Conversely, patients with prior CABG less frequently received invasive therapy. Future studies should determine the appropriateness of this treatment discrepancy.
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Citation: Am Heart J. 2010 Jan;159(1):40-6. Link to article on publisher's site