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Strategy of very early invasive angiography does not improve long-term outcomes
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MUNICH — Very early invasive coronary angiography and possible revascularization within 12 hours of diagnosis did not improve long-term clinical outcomes compared with a standard invasive strategy within 48 to 72 hours in patients presenting with non-ST-segment elevation ACS, according to new data from the VERDICT trial.
Researchers analyzed 2,147 patients in Denmark with clinical suspicion of non-ST-segment elevation ACS (NSTE-ACS) and ECG changes that indicated new ischemia or elevated troponin. Patients were randomly assigned to standard invasive coronary angiography within 48 to 72 hours (n = 1,072; median, 61.6 hours after randomization) or very early invasive coronary angiography within 12 hours (n = 1,075; median, 4.7 hours after randomization), followed by possible PCI or CABG. Coronary revascularization was performed in 88% of the early-strategy group and 83% of the standard-strategy group with significant CAD identified by invasive coronary angiography.
The primary endpoint, a composite of all-cause mortality, nonfatal MI, hospitalization for refractory myocardial ischemia or hospitalization for HF, occurred in 27.5% of the early-strategy group vs. 29.5% of the standard-strategy group (HR = 0.92; 95% CI, 0.78-1.08) during a median follow-up of 4.3 years.
In other results, there was a significant reduction in recurrent MI in patients assigned the early invasive strategy (HR = 0.73; 95% CI, 0.56-0.96) and a borderline significant reduction in HF (HR = 0.78; 95% CI, 0.6-1.01).
When researchers analyzed outcomes by GRACE score, patients in the early-strategy group with a score greater than 140 exhibited improvement in the primary outcome compared with the standard-strategy group (HR = 0.81; 95% CI, 0.67-1).
“If you turn things upside-down, you could say that a very early invasive look-up in [NSTE-ACS] is safe, complications were equally distributed between the two groups and it is possibly favorable for some of the patients,” Thomas Engstrøm, MD, DSci, PhD, professor at Rigshospitalet, Copenhagen University, Denmark, said during the presentation. “However, if you assume that acute investigation should be offered to everybody, there is a clear logistical challenge, and it is potentially not also cost-effective.”
Discussing the findings, Engstrøm said, “for now, the task will be to choose the right patients for very early strategy. To put things into perspective, you need to treat 73 patients with a GRACE score above 140 to save one patient from the primary endpoint. Our suggestion for future triage will be to take those with GRACE score > 140 within 12 hours.” – by Darlene Dobkowski
References:
Engstrøm T, et al. Hot Line Late Breaking Clinical Trials 4. Presented at: European Society of Cardiology Congress; Aug. 25-29, 2018; Munich.
Kofoed KF, et al. Circulation. 2018;doi:10.1161/CIRCULATIONAHA.118.037152.
Disclosure: Engstrøm reports he receives personal fees from Abbott, Bayer, Boston Scientific, Medtronic and Novo Nordisk.
Editor’s Note: This article was updated on Aug. 31, 2018 with a small modification to the data.
Perspective
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Joep Perk, MD, PhD, FESC
Over the years, we have become more aggressive to get patients to the cath lab. Recent data from the SWEDEHEART registries showed that we are using more PCI but without affecting mortality rates. Maybe we have to revisit the idea of being enormously in a hurry to get to the cath lab as soon as we see any signs of ischemia. What this study says is that if there is a gut feeling from the doctor, but it is not an acute case, you have time to work up the patient and do not to need to rush them to the cath lab. We will not think you are a poor doctor if you do not rush them to the cath lab right away.
These findings have the potential to change clinical practice. They could relieve the pressure to go to the cath lab as soon as chest pain is diagnosed. The message is now clearer that you have time to determine the best path for the patient, considering risk levels and other factors.
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