An invasive strategy is associated with decreased mortality in patients with unstable angina and non–ST-elevation myocardial infarction: GUSTO IIb trial

doi:10.1016/S0002-9343(02)01446-8

The American Journal of Medicine

Volume 114, Issue 2, 1 February 2003, Pages 106-111

https://doi.org/10.1016/S0002-9343(02)01446-8 Get rights and content

Abstract

Purpose

There has been much debate concerning an invasive versus a conservative strategy for patients with acute coronary syndromes. The purpose of this study was to determine whether early in-hospital catheterization reduced mortality in patients with unstable angina and non–ST-elevation myocardial infarction.

Methods

We performed a retrospective analysis of data collected in the Global Use of Strategies to Open Occluded Coronary Arteries (GUSTO) IIb trial, which compared hirudin and heparin in patients with acute coronary syndromes. We identified 8011 patients with non–ST-segment elevation myocardial infarction and unstable angina who were enrolled in the trial. The primary endpoints were all-cause mortality at 30 days and 1 year. Data were analyzed with multivariate hazards models and propensity scores.

Results

After accounting for inception time bias, there were 7897 patients identified, of whom 4536 patients (57%) underwent invasive therapy and 3361 (43%) underwent conservative therapy. Adjusting for propensity scores, the adjusted 30-day mortality for the invasive group was 2.5% compared with 2.7% in the conservative group (P = 0.92); at 1 year, the invasive group had a 6.2% mortality, versus 8.6% in the conservative group (P = 0.005). In a multivariate analysis that adjusted for other clinical factors, an invasive strategy was associated with lower 1-year mortality (hazard ratio = 0.46; 95% confidence interval: 0.10 to 0.84).

Conclusion

In patients presenting with acute coronary syndromes, an invasive strategy is associated with improved survival at 1 year even after adjusting for baseline differences.

Section snippets

Study group

Prospective data were collected from patients enrolled in the GUSTO IIb trial (10). Briefly, the inclusion criteria consisted of chest pain within the previous 12 hours that was associated either with transient or persistent ST-segment elevation or depression of more than 0.5 mm, or with persistent, definite T-wave inversion of more than 1 mm. A total of 12,142 patients were enrolled in the trial. For our analysis, we included the 8011 patients who did not have ST-segment elevation. Of those,

Results

After eliminating patients with missing catheterization information and patients who died before the median time to catheterization, there were 7897 patients in our analysis. Of those, 4536 patients (57%) underwent in-hospital catheterization, including 2591 (57%) who underwent revascularization: 1585 (63%) with percutaneous coronary intervention and 1006 (40%) with coronary artery bypass grafting. The remainder of the patients (n = 3361 [43%]) did not undergo catheterization prior to

Discussion

The optimal utilization of cardiac catheterization and coronary revascularization for patients with unstable angina and non–ST-elevation myocardial infarction remains controversial. Whereas the TIMI IIIB and VANQWISH trials did not show a benefit with an early invasive strategy, the FRISC II and TACTICS-TIMI 18 trials did report that invasive therapy led to better outcomes 5, 6, 7, 8, 9. Our data from a large cohort of patients with acute coronary syndromes suggest that an invasive strategy is

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Outcomes in patients with non-ST-elevation acute coronary syndrome randomly assigned to invasive versus conservative treatment strategies: A metaanalysis
2014, Clinics
The goal of the present study was to compare the prognoses of patients with non-ST-elevation acute coronary syndromes who were treated with invasive or conservative treatment strategies.
We performed a meta-analysis of studies of patients with non-ST-elevation acute coronary syndromes to assess the benefits of an invasive strategy vs. a conservative strategy for short- and long-term survival. We searched PubMed for studies published from 1990 to November 2012 that investigated the effects of an invasive vs. conservative strategy in patients with non-ST-elevation acute coronary syndromes. The following search terms were used: “non-ST-elevation myocardial infarction”, “unstable angina”, “acute coronary syndromes”, “invasive strategy”, and “conservative strategy”. The primary endpoints were all-cause mortality at 30 days and 1 year.
Seven published studies were included in the present meta-analysis. The pooled analyses show that an invasive strategy decreased the risk of death (risk ratio [0.839] [95% confidence interval {0.648-1.086}; I², 86.46%] compared to a conservative strategy over a 30-day-period. Furthermore, invasive treatment also decreased patient mortality (risk ratio [0.276] [95% confidence interval {0.259-0.294}; I², 94.58%]) compared to a conservative strategy for one year.
In non-ST-elevation acute coronary syndromes, an invasive strategy is comparable to a conservative strategy for decreasing short- and long-term mortality rates.
Mean length of stay and prognosis in unstable angina. Results from the ARIAM database
2007, Medicina Clinica
El propósito de este trabajo es investigar los factores predictores de mortalidad y la estancia media de los pacientes diagnosticados de angina inestable (AI) durante su ingreso en las unidades de cuidados intensivos o unidades de cuidados coronarios (UCI/UCC).
Estudio de cohorte retrospectivo que incluyó a los pacientes del registro español ARIAM (Análisis del Retraso en el Infarto Agudo de Miocardio). El período de estudio comprendió de junio de 1996 a diciembre de 2003. Su seguimiento se limitó a UCI/UCC. Se realizó un análisis univariante entre los pacientes fallecidos y los vivos y otro entre los pacientes con estancia prolongada y no prolongada. Se realizaron además 3 análisis multivariantes con el objetivo de evaluar los factores relacionados con la mortalidad, las variables asociadas a la realización de intervención coronaria percutánea (ICP) y los factores asociados a la estancia media prolongada en UCI/UCC.
Se incluyó a 14.096 pacientes con AI. La mortalidad fue del 1,1% y se asoció a la clase Killip, edad, necesidad de reanimación cardiopulmonar y presencia de shock cardiogénico,arritmias y diabetes; mientras que los pacientes fumadores se asociaron a una menor mortalidad. Se realizó ICP sólo a 1.226 (8,9%) pacientes, aunque su realización se incrementó con los años. La ICP se asoció a edad, traslado interhospitalario, tabaquismo, infarto de miocardio previo, shock cardiogénico o ante el bloqueo auriculoventricular de alto grado (BAVAG) y tratamiento con bloqueadores beta. La estancia media (desviación estándar) fue de 3,15 (18,65) días. La estancia media prolongada dependió de la edad, haber sido sometido a una coronariografía o ICP, clase Killip,ecocardiografía o ventilación mecánica y presentar complicaciones graves.
La mortalidad se explica por la comorbilidad y la gravedad de la isquemia. Los pacientes a los que se realiza ICP son una población menos grave, y su realización con el tiempo se incrementa. La estancia media prolongada se asocia a la mayor gravedad de la isquemia miocárdica y a la ICP.
The objective of this project is to investigate the factors predicting mortality and mean length of stay in patients diagnosed with unstable angina (UA) during admission to the Intensive Care Unit or Critical Care Unit (ICU/CCU).
A retrospective cohort study including all the UA patients listed in the Spanish ARIAM register. The study period comprised from June, 1996 to December, 2003. The followup period is limited to the stay in the ICU/CCU. One univariate analysis was performed between deceased and live patients; and another between prolonged and non-prolonged stay patients. Three multivariate analyses were also performed; one to evaluate the factors related to mortality,another to evaluate the variables associated to percutaneous coronary intervention (PCI) and another to evaluate the factors associated to the prolonged mean stay in ICU/CCU.
14,096 patients with UA were included in the study. The UA mortality rate during ICU/CCU admission was 1.1%. Mortality was associated to Killip classification, age, the need for CPR, development of cardiogenic shock, development of arrhythmia (such as VF, sinus tachycardia or high-degree atrioventricular block) and diabetes; whereas patients who smoke were associated to a lower mortality rate. PCI was only performed in 1,226 patients (8.9%), increasing over the years. The PCI-predicting variables were: age, being referred from another hospital, smoking, presenting prior acute myocardial infarction (AMI), complications consisting of cardiogenic shock or high-degree atrioventricular block and being treated with oral beta blockers. The mean length of stay in ICU/CCU was 3.15 (18.65) days (median, 2 days), depending on age, a coronariography having previously been performed, the Killip classification,having required coronariography and PCI or echocardiography or mechanical ventilation, and presenting complications such as angina that is difficult to control, arrhythmia, right ventricular failure or death.
The factors are associated to mortality were; greater age, diabetes, Killip classification,arrhythmia, cardiogenic shock and the need for CPR, whereas smoking is associated to a lower mortality rate. The patients on whom PCI was performed represent a less severe population. Management has changed over the years, with an increase in PCI. A prolonged mean length of stay is associated to the appearance of arrhythmia, right or left heart failure, angina that is difficult to control, age and PCI.
A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods
2006, Journal of Clinical Epidemiology
Citation Excerpt :
We excluded 48 articles that did not include analysis of data (28), randomized clinical trials (9), case-control studies (2), and articles primarily analyzing cost-effectiveness (6) or practice patterns (3). Our search revealed 58 substantive medical research studies that used PS in 2003 [18–75], 38 in 2002 [76–113], 28 in 2001 [114–141], 6 in 2000 [142–147], 5 in 1999 [148–152], 5 in 1998 [153–157], and a total of 5 before 1998 [158–162]. Additional articles found through a citation search of the significant methods articles written about PS, using Science Citation Index, yielded 13 medical research studies that used PS in 2003 [163–175], 13 in 2002 [176–188], 11 in 2001 [189–199], 3 in 2000 [200–202], 1 in 1999 [203], 3 in 1998 [204–206], and a total of 3 before 1998 [207–209].
Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling.
Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003.
Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N = 60) or surgical interventions (N = 51), mainly in cardiology and cardiac surgery (N = 90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented.
Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.
Relation of timing of cardiac catheterization to outcomes in patients with non-ST-segment elevation myocardial infarction or unstable angina pectoris enrolled in the multinational Global Registry of Acute Coronary Events
2005, American Journal of Cardiology
Citation Excerpt :
The present analysis used data from patients who had been hospitalized with a diagnosis of unstable angina pectoris or NSTEMI, had undergone early invasive management with standard catheterization procedures, and were enrolled in the Global Registry of Acute Coronary Events. Previously reported trials have addressed the use of invasive management strategies in patients who have unstable angina pectoris or NSTEMI,1–5,15–19 and some have shown benefits over conservative strategies for long-term outcomes.1–5,17–19 However, there have been few reports that have specifically investigated the effect of timing of catheterization in this category of patients who have ACS.6,8
We assessed whether timing of catheterization is associated with the type of non-ST-segment elevation acute coronary syndrome and/or outcome in patients who were enrolled in the Global Registry of Acute Coronary Events. Overall, 8,853 patients who had unstable angina pectoris or non-ST-elevation myocardial infarction were categorized according to timing of catheterization: expeditive (<24 hours), early (24 to 48 hours), and delayed (>48 hours). Patients in the delayed group were older, more frequently had previous myocardial infarction or stroke, and had a higher risk score compared with those in the expeditive and early groups (all p ≤0.001). Killip class IV at admission, non-ST-elevation myocardial infarction, and Q waves after the index electrocardiogram were more common in the expeditive group (all p <0.0001). Patients in the expeditive and early groups were treated more aggressively with medications than were those in the delayed group. The in-hospital composite end point (death, stroke, or major bleed) occurred most frequently in the expeditive group (expeditive 6.6%, early 3.9%, delayed 5.1%, p = 0.0005), as did in-hospital death (expeditive 3.5%, early 1.4%, delayed 2.0%, p <0.0001). The highest incidence of death during follow-up occurred in the delayed group (3.8% delayed vs 2.8% expeditive/early, p = 0.0210). Multivariate regression analysis suggested that expeditive catheterization was related to in-hospital death and death from time of catheterization to 6 months. We conclude that expeditive catheterization is associated with unstable presenting features that contribute significantly to the higher risk of death and death or myocardial infarction in hospital compared with patients who undergo later catheterization.
Outcome analysis of one year after an invasive compared with noninvasive strategy in unstable angina
2019, Pakistan Journal of Medical and Health Sciences
Early Invasive Strategy for Unstable Angina: A New Meta-Analysis of Old Clinical Trials
2016, Scientific Reports

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Clinical studyAn invasive strategy is associated with decreased mortality in patients with unstable angina and non–ST-elevation myocardial infarction: GUSTO IIb trial

Abstract

Purpose

Methods

Results

Conclusion

Section snippets

Study group

Results

Discussion

Am J Cardiol

Am J Cardiol

Prog Cardiovasc Dis

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Cardiol

Clinical study
An invasive strategy is associated with decreased mortality in patients with unstable angina and non–ST-elevation myocardial infarction: GUSTO IIb trial