Paul-Georges Reuter1, Cécile Rouchy2, Simon Cattan3, Hakim Benamer4, Thierry Jullien5, Ariel Beruben6, Jean-Michel Montely7, Nathalie Assez8, Valérie Raphael9, Brigitte Hennequin10, Albert Boccara11, Nicolas Javaud12, Louis Soulat2, Frédéric Adnet13, Frédéric Lapostolle13. 1. Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009 Bobigny Cedex, France; Université Paris 13, Sorbonne Paris Cité, EA 3509 Bobigny, France. Electronic address: paul-georges.reuter@avc.aphp.fr. 2. Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier de Châteauroux, 216 Avenue de Verdun, 36000 Châteauroux, France. 3. Département de Cardiologie, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, 10 Rue du Général Leclerc, 93370 Montfermeil, France. 4. Département de Cardiologie, Clinique la Roseraie, 120 Avenue de la République, 93300 Aubervilliers, France. 5. Département de Cardiologie, Centre Cardiologique du Nord, 36 Rue des Moulins Gémeaux, 93200 Saint-Denis, France. 6. Service Mobile d'Urgence et de Réanimation, Groupe Hospitalier Intercommunal Le Raincy-Montfermeil, 10 Rue du Général Leclerc, 93370 Montfermeil, France. 7. Département de Cardiologie, Centre Hospitalier Intercommunal Robert Ballanger, Boulevard Robert Ballanger, 93600 Aulnay-sous-Bois, France. 8. Service d'Aide Médicale Urgente du Nord Pôle de l'Urgence, Centre Hospitalier Régional Universitaire de Lille, 5 avenue Oscar-Lambret, 59037 Lille Cedex, France. 9. Service Mobile d'Urgence et de Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, Boulevard Robert Ballanger, 93600 Aulnay-sous-Bois, France. 10. Service Mobile d'Urgence et de Réanimation, Centre hospitalier de Saint-Denis, 2 Rue du Docteur Delafontaine, 93200 Saint-Denis, France. 11. Département de Cardiologie, Centre Hospitalier Intercommunal André Grégoire, 56 Boulevard de la Boissière, 93100 Montreuil, France. 12. Service des Urgences, Centre Hospitalier Universitaire Jean Verdier, Assistance Publique-Hôpitaux de Paris, Avenue du 14 Juillet, 93140 Bondy, France. 13. Service des Urgences et Service d'Aide Médicale Urgente, Centre Hospitalier Universitaire Avicenne, Assistance Publique-Hôpitaux de Paris, 125 rue de Stalingrad, 93009 Bobigny Cedex, France; Université Paris 13, Sorbonne Paris Cité, EA 3509 Bobigny, France.
Abstract
BACKGROUND: The optimal therapeutic strategy for patients with high-risk acute coronary syndrome without ST-segment elevation (NSTE-ACS) remains unclear. OBJECTIVE: Our aim was to compare the effectiveness of an early invasive strategy and a delayed invasive strategy in the management of high-risk NSTE-ACS patients. METHODS: This randomized clinical trial in a primarily pre-hospital setting enrolled patients with chest pain, electrocardiographic criteria for an NSTE-ACS, and at least one criterion of severity (ESC criterion or TIMI score >5). Patients were randomized to either an early invasive strategy (tirofiban infusion and coronary angiography within 6h) or delayed invasive strategy (as per guidelines and physician discretion; coronary angiography within 6h was not advised). The primary endpoint was the cumulative incidence of deaths, myocardial infarctions, or urgent revascularizations at 30days of follow-up. Secondary endpoints were failure of delayed management, length of hospital stay and long-term mortality. RESULTS:Between January 2007 and February 2010, 170 patients were enrolled. The cumulative incidence of adverse outcomes was significantly lower for early invasive than delayed management (2% [95% CI 0-9] vs. 24% [95% CI 16-35], p<10(-4)). Delayed management failed in 24% of cases. The length of hospital stay was significantly shorter in patients undergoing angioplasty or treated with tirofiban within 6h (p=0.0003). Long-term mortality was 16% in both arms after a median follow-up of 4.1years. CONCLUSION: An early invasive strategy reduced major adverse cardiac events in patients with high-risk NSTE-ACS. Early angiography or tirofiban (GP IIb/IIIa inhibitor) infusion proved necessary in a quarter of patients assigned to delayed management.
RCT Entities:
BACKGROUND: The optimal therapeutic strategy for patients with high-risk acute coronary syndrome without ST-segment elevation (NSTE-ACS) remains unclear. OBJECTIVE: Our aim was to compare the effectiveness of an early invasive strategy and a delayed invasive strategy in the management of high-risk NSTE-ACS patients. METHODS: This randomized clinical trial in a primarily pre-hospital setting enrolled patients with chest pain, electrocardiographic criteria for an NSTE-ACS, and at least one criterion of severity (ESC criterion or TIMI score >5). Patients were randomized to either an early invasive strategy (tirofiban infusion and coronary angiography within 6h) or delayed invasive strategy (as per guidelines and physician discretion; coronary angiography within 6h was not advised). The primary endpoint was the cumulative incidence of deaths, myocardial infarctions, or urgent revascularizations at 30days of follow-up. Secondary endpoints were failure of delayed management, length of hospital stay and long-term mortality. RESULTS: Between January 2007 and February 2010, 170 patients were enrolled. The cumulative incidence of adverse outcomes was significantly lower for early invasive than delayed management (2% [95% CI 0-9] vs. 24% [95% CI 16-35], p<10(-4)). Delayed management failed in 24% of cases. The length of hospital stay was significantly shorter in patients undergoing angioplasty or treated with tirofiban within 6h (p=0.0003). Long-term mortality was 16% in both arms after a median follow-up of 4.1years. CONCLUSION: An early invasive strategy reduced major adverse cardiac events in patients with high-risk NSTE-ACS. Early angiography or tirofiban (GP IIb/IIIa inhibitor) infusion proved necessary in a quarter of patients assigned to delayed management.
Authors: Eliano P Navarese; Bernhard Wernly; Michael Lichtenauer; Martino Pepe; Wojciech Wanha; Giuseppe Ferrante; Lara Frediani; Verena Veulemans; Tobias Zeus; Ralf Westenfeld; Christian Jung; Paul A Gurbel Journal: J Thorac Dis Date: 2018-01 Impact factor: 2.895
Authors: Thomas A Kite; Amerjeet S Banning; Andrew Ladwiniec; Chris P Gale; John P Greenwood; Miles Dalby; Rachel Hobson; Shaun Barber; Emma Parker; Colin Berry; Marcus D Flather; Nick Curzen; Adrian P Banning; Gerry P McCann; Anthony H Gershlick Journal: BMJ Open Date: 2022-05-03 Impact factor: 3.006
Authors: Erik A Badings; Wouter S Remkes; Salem H K The; Jan-Henk E Dambrink; Geert Tjeerdsma; Saman Rasoul; Jorik R Timmer; Marloes L J van der Wielen; Dirk J A Lok; Renicus S Hermanides; Jan Van Wijngaarden; Harry Suryapranata; Arnoud W J van 't Hof Journal: Open Heart Date: 2017-03-02
Authors: H Pendell Meyers; Alexander Bracey; Daniel Lee; Andrew Lichtenheld; Wei J Li; Daniel D Singer; Zach Rollins; Jesse A Kane; Kenneth W Dodd; Kristen E Meyers; Gautam R Shroff; Adam J Singer; Stephen W Smith Journal: Int J Cardiol Heart Vasc Date: 2021-04-12
Authors: Thomas A Kite; Sameer A Kurmani; Vasiliki Bountziouka; Nicola J Cooper; Selina T Lock; Chris P Gale; Marcus Flather; Nick Curzen; Adrian P Banning; Gerry P McCann; Andrew Ladwiniec Journal: Eur Heart J Date: 2022-09-01 Impact factor: 35.855