Early invasive strategy lowers in-hospital death in women with non‒ST-elevation MI
An early invasive strategy, as compared with an initial conservative strategy, may reduce in-hospital mortality in women with non‒ST-elevation myocardial infarction (MI), according to a recent study.
“This benefit was observed in women presenting with non‒ST-elevation MI but not with unstable angina,” researchers said. “Moreover, an early invasive strategy was associated with a shorter length of stay and higher total hospital charges.”
To assess whether an early invasive strategy in women is associated with better outcomes in real-world data, researchers identified 372,080 women admitted with a primary diagnosis of non‒ST-elevation MI or unstable angina from the National Inpatient Sample years 2012 and 2013.
A propensity score-matched analysis was used to compare the incidence of in-hospital mortality in women with non‒ST-elevation acute coronary syndrome undergoing an early invasive strategy vs an initial conservative strategy.
Of the participants, 153,680 (41.3 percent) received an early invasive strategy and 218,400 (58.7 percent) were managed with an initial conservative strategy. Propensity score-matched 19,965 women were treated with an early invasive strategy and 20,009 patients with an initial conservative strategy. [Am J Med 2017;130:1059–1067]
Women who were managed with an early invasive strategy had a lower risk of in-hospital mortality compared with those who were treated with an initial conservative strategy (2.1 vs 3.8 percent; odds ratio [OR], 0.55; 95 percent CI, 0.49 to 0.62). This benefit was seen in women presenting with non‒ST-segment elevation MI (OR, 0.52; 0.46 to 0.58) but not in those with unstable angina (OR, 5.14; 0.47 to 56.9; p=0.06 for interaction).
The results were similar on propensity-adjusted analysis (OR, 0.51; 0.45 to 0.57).
“These findings support the 2014 American Heart Association/American College of Cardiology guideline for the management of patients with non–ST-elevation acute coronary syndrome, which endorses an early invasive strategy in women with high-risk features only (eg, troponin positive),” researchers said.
A patient-level analysis of eight randomized trials (n=3,075 women), which compared both strategies and were powered for the composite outcomes rather than mortality, showed that three of the included trials predated the era of stents and contemporary antiplatelet therapy. [J Am Coll Cardiol 2010;55:2435–2445]
The findings revealed an association between an early invasive strategy and a lower risk of the composite of mortality, MI or hospitalization for acute coronary syndrome at 12 months in biomarker-positive women (OR, 0.67; 0.50 to 0.88), but not in those with negative biomarkers (OR, 0.94; 0.61 to 1.44). Furthermore, no difference was observed in mortality risk between both strategies at 12 months (OR, 1.11; 0.72 to 1.70). [JAMA 2008;300:71–80]
“To date, only two randomized trials have attempted to compare both strategies exclusively in women; one of these trials was relatively small (ie, enrolled only 40 women) and showed no difference in clinical outcomes,” researchers noted. [Eur Heart J 2012;33:51–60; Cardiol Ther 2016;5:43–50]
“In the Organization to Assess Strategies in Acute Ischemic Syndromes 5 substudy in women, an early invasive strategy was associated with a higher risk of mortality at 1 year, which could have been driven by the increased risk of major bleeding at 30 days,” they added. [Eur Heart J 2012;33:51–60]