Early Pci Is The Treatment Of Choice For Patients With Highrisk

The Big Heart Disease Lie

Curing Cardiovascular Disease Permanently

Get Instant Access

In recent registry data from Washington State, patients with NSTEMI who were admitted to hospitals that favored an early invasive treatment strategy had 30-d and 4-yr mortality rates that were almost 50% lower than those admitted to hospitals that favored a conservative treatment strategy (32). It should be noted that fibrinolytic therapy is not indicated in patients with NSTEMI and may be harmful (12,33).

Previous randomized trials of early aggressive vs conservative approaches in UA and NSTEMI have had conflicting results. These were conducted before the common usage of stents and GP IIb/IIIa antagonists (34-37). The Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial randomized patients with non-Q wave AMI to an early invasive strategy vs noninvasive risk stratification (34). In VANQWISH, there was an excess risk of the invasive approach, which was entirely a direct result of a high surgical mortality of 11.6% in the invasive group. This operative mortality rate does not reflect current experience, and thus, the conclusions of the VANQWISH study thus cannot be applied to patients at centers with lower operative mortalities. Conversely, the Thrombolysis in Myocardial Infarction (TIMI) 3B trial showed less recurrent ischemia and fewer and shorter hospitalizations at 1 yr in patients randomized to routine early (18-48 h) cardiac catheterization and revascularization, compared to conservative management (37).

The use of early PCI in patients with ACS has been re-examined in two other recent trials and a recently reported registry. The Second Fragmin and Fast Revascularization during Instability in Coronary Artery Disease (FRISC II) trial demonstrated an improvement in the combined rate of death or AMI at 6 mo in patients with high-risk ACS using an early invasive approach compared to a stepwise selective invasive approach (36). This trial also showed that patients with ST-segment depression on admission electrocardiogram (ECG) had more severe coronary disease; in these patients, an early invasive strategy substantially decreased the combined rate of death and AMI. Now, 2-yr follow-up results of FRISC II have demonstrated a 4.2% reduction in death and AMI with the early invasive approach (38). The event curves continued to separate over the 2 yr, even though half of the patients in the conservative arm ultimately underwent revascularization. Patients with ST-segment depression and elevated troponin, at the highest risk, benefited the most: the 1-yr risk of death or AMI was reduced by nearly 50% with the early invasive approach compared to the conservative approach (14 vs 25%, respectively).

The Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy—Thrombolysis in Myocardial Infarction (TACTICS-TIMI) -18 trial randomized 2220 patients with ACS to early coronary angiography within 4-48 h of presentation vs a more conservative ischemia-guided approach, both groups being treated with tirofiban (39). Enrollment criteria included accelerating angina and either ischemic ECG changes, elevated serum cardiac markers (troponin or creatine kinase isoenzyme-cardiac muscle subunit [CK-MB]), or previous AMI or coronary revascular-ization. The composite end point of death, acute MI, or rehospitalization for recurrent UA at 6 mo was significantly reduced in patients treated with an early invasive approach (Table 1), with the greatest benefit conferred to patients with ischemic ECG changes or elevated troponin levels.

Table 1

Six-Month Outcomes of TACTICS-TIMI-18: Prospective Randomized Trial Comparing Early Coronary .Angiography Vs Ischemia-Guided Therapy in Patients with ACS Treated with

Tirofiban (39)

Table 1

Six-Month Outcomes of TACTICS-TIMI-18: Prospective Randomized Trial Comparing Early Coronary .Angiography Vs Ischemia-Guided Therapy in Patients with ACS Treated with

Tirofiban (39)

Was this article helpful?

0 0
Your Heart and Nutrition

Your Heart and Nutrition

Prevention is better than a cure. Learn how to cherish your heart by taking the necessary means to keep it pumping healthily and steadily through your life.

Get My Free Ebook


Post a comment