TY - JOUR

T1 - Importance of risk assessment in timing of invasive coronary evaluation and treatment of patients with non–st-segment– elevation acute coronary syndrome

T2 - Insights from the verdict trial

AU - Butt, Jawad H.

AU - Kofoed, Klaus F.

AU - Kelbæk, Henning

AU - Hansen, Peter R.

AU - Torp-Pedersen, Christian

AU - Høfsten, Dan

AU - Holmvang, Lene

AU - Pedersen, Frants

AU - Bang, Lia E.

AU - Sigvardsen, Per E.

AU - Clemmensen, Peter

AU - Linde, Jesper J.

AU - Heitmann, Merete

AU - Hove, Jens Dahlgaard

AU - Abdulla, Jawdat

AU - Gislason, Gunnar

AU - Engstrøm, Thomas

AU - Køber, Lars

N1 - Publisher Copyright: © 2021 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

PY - 2021

Y1 - 2021

N2 - BACKGROUND: The optimal timing of invasive examination and treatment of high-risk patients with non–ST-segment–elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard-care invasive coronary angiography on the risk of all-cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. METHODS AND RESULTS: Patients with clinical suspicion of non–ST-segment–elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48–72 hours) invasive strategy. The primary outcome of the present study was all-cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow-up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16–3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63–1.10]) (Pinteraction =0.006). CONCLUSIONS: In patients with non–ST-segment–elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high-risk and low-risk patients with non–ST-segment–elevation acute coronary syndrome. REGISTRATION: URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02061891.

AB - BACKGROUND: The optimal timing of invasive examination and treatment of high-risk patients with non–ST-segment–elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard-care invasive coronary angiography on the risk of all-cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. METHODS AND RESULTS: Patients with clinical suspicion of non–ST-segment–elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48–72 hours) invasive strategy. The primary outcome of the present study was all-cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow-up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16–3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63–1.10]) (Pinteraction =0.006). CONCLUSIONS: In patients with non–ST-segment–elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high-risk and low-risk patients with non–ST-segment–elevation acute coronary syndrome. REGISTRATION: URL: https://www.clini​caltr​ials.gov; Unique identifier: NCT02061891.

KW - Acute coronary syndrome

KW - GRACE score

KW - Heart failure

KW - Invasive coronary angiography

KW - Mortality

U2 - 10.1161/JAHA.121.022333

DO - 10.1161/JAHA.121.022333

M3 - Journal article

C2 - 34585591

AN - SCOPUS:85118097021

VL - 10

JO - Journal of the American Heart Association

JF - Journal of the American Heart Association

SN - 2047-9980

IS - 19

M1 - e022333

ER -