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Very early invasive care not superior to standard approach in NSTE-ACS

Christina Lau
10 Sep 2018
Professor Thomas Engstrøm presenting results of the VERDICT trial at ESC 2018

Very early invasive coronary angiography within 12 hours does not significantly improve long-term outcomes of patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) compared with the standard strategy of evaluation within 48–72 hours, according to results of the VERDICT trial reported at the European Society of Cardiology (ESC) Congress 2018.

After a median follow-up of 4.3 years, the primary composite outcome of all-cause mortality, nonfatal recurrent MI, hospitalization for heart failure, or hospitalization for refractory myocardial ischaemia occurred in 27.5 percent of patients randomized to undergo very early invasive coronary angiography (performed within a median of 4.7 hours), compared with 29.5 percent of patients who received standard invasive evaluation (performed within a median of 61.6 hours). No significant difference was observed between the two groups (hazard ratio [HR], 0.92; 95 percent confidence interval [CI], 0.78 to 1.08; p=0.29). [Circulation 2018, doi: 10.1161/CIRCULATIONAHA.118.037152]

“However, in the subgroup of patients with the highest risk, who had a Global Registry of Acute Coronary Events [GRACE] score above 140, a significant 19 percent improvement in the primary outcome was observed with the very early vs standard invasive strategy [34 percent vs 40 percent; HR, 0.81; 95 percent CI, 0.67 to 1.00; p interaction=0.023], with a number-needed-to-treat of 5 to 6,” reported investigator Professor Thomas Engstrøm of the Copenhagen University Hospital, Denmark.

In terms of secondary outcomes, no significant differences were observed between very early and standard invasive care in all-cause mortality (HR, 0.97; 95 percent CI, 0.76 to 1.23; p=0.79), heart failure (HR, 0.78; 95 percent CI, 0.60 to 1.01; p=0.06) and refractory ischaemia (HR, 1.32; 95 percent CI, 0.91 to 1.91; p=0.14). “However, patients who received very early invasive care had a significant reduction in nonfatal MI compared with those in the standard invasive care group [HR, 0.73; 95 percent CI, 0.56 to 0.96; p=0.025],” said Engstrøm.

In the study, 2,147 patients (mean age, 64 years; 66 percent male) admitted for suspected NSTE-ACS were randomized 1:1 to undergo very early invasive coronary angiography within 12 hours or standard invasive evaluation within 48–72 hours, followed by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG).

In the very early invasive care group, 68 percent of patients with significant coronary artery disease (CAD) were treated with PCI, 18 percent underwent CABG, and 14 percent received medical therapy. In the standard invasive care group, 60 percent of patients with significant CAD underwent PCI, 18 percent were treated with CABG, and 22 percent received medical therapy.

A majority of patients in both groups had one lesion treated (77.3 percent in very early group vs 80.1 percent in standard group). More than half of the patients in each group used one stent during revascularization procedure (59.8 percent in very early group vs 64.7 percent in standard group), while two stents were used in less than one-fourth of the patients (22.3 percent vs 21.3 percent).

“Our results show that very early invasive look-up in NSTE-ACS is safe and possibly favourable for some patients. However, given the high number of NSTE-ACS patients, acute investigation is logistically challenging and potentially not cost-effective,” Engstrøm commented.

“Nevertheless, patients presenting with symptoms of ACS with troponin rise and a high GRACE score should be examined within 12 hours,” he suggested.

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