Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularization

doi:10.1016/j.ahj.2009.09.019

American Heart Journal

Volume 159, Issue 1, January 2010, Pages 40-46

https://doi.org/10.1016/j.ahj.2009.09.019 Get rights and content

Background

Contemporary guidelines support an early invasive strategy for non-ST elevation acute coronary syndrome (NSTE-ACS) patients who had prior coronary revascularization. However, little is known about the management pattern of these patients in “real world.”

Methods

We analyzed 3 consecutive Canadian registries (ACS I, ACS II, and Global Registry of Acute Coronary Events [GRACE]/expanded-GRACE) that recruited 12,483 NSTE-ACS patients from June 1999 to December 2007. We stratified the study population according to prior coronary revascularization status into 4 groups and compared their clinical characteristics, in-hospital use of medications, and cardiac procedures.

Results

Of the 12,483 NSTE-ACS patients, 71.2% had no prior revascularization, 14.2% had percutaneous coronary intervention (PCI) only, 9.5% had coronary artery bypass graft surgery (CABG) only, and 5% had both PCI and CABG. Compared to their counterparts without prior revascularization, patients with previous PCI and/or CABG were more likely to be male, to have diabetes, myocardial infarction, and heart failure but less likely to have ST-segment deviation or positive cardiac biomarker on presentation. Early use of evidence-based medications was higher among patients with previous PCI only and lower among patients with previous CABG only. After adjusting for possible confounders including GRACE risk score, prior PCI was independently associated with in-hospital use of cardiac catheterization (adjusted odds ratio [OR] 1.18, 95% CI 1.04-1.34, P = .008). In contrast, previous CABG was an independent negative predictor (adjusted OR .77, 95% CI 0.68-0.87, P < .001). There was no significant interaction (P = .93) between previous PCI and CABG.

Conclusions

The NSTE-ACS patients with previous PCI were more likely to be treated invasively. Conversely, patients with prior CABG less frequently received invasive therapy. Future studies should determine the appropriateness of this treatment discrepancy.

Section snippets

Study design

Details of the Canadian Acute Coronary Syndrome Registries (ACS I and ACS II)9, 10 and the Global Registry of Acute Coronary Events (GRACE/expanded-GRACE)5, 6, 7, 8 have been previously described. Briefly, the Canadian ACS Registries were prospective, multicenter, observational studies focusing on the epidemiology, management practices, and outcomes of ACS.⁹ In ACS Registry I, 51 Canadian hospitals provided data during the period between September 1999 and June 2001. Thirty-six Canadian centers

Study population characteristics

Baseline demographic and clinical characteristics of 12,483 patients with NSTE-ACS, divided into 4 groups according to prior coronary revascularization status are shown in Table I. Of the 12,483 patients, 8,884 (71.2%) of patients had no prior revascularization, 1,773 (14.2%) had PCI only, 1,193 (9.5%) had CABG only, and 633 (5%) had both PCI and CABG. Overall, the median (25th-75th percentile) GRACE risk score was 119 (96-147).

Compared to the no prior PCI/CABG group, patients in the PCI only,

Discussion

In this large observational study, we found that patients with history of PCI presenting with NSTE-ACS were more likely to be managed invasively, which is consistent with the current guideline recommendations.⁴ Conversely, despite guideline recommendations, patients with previous CABG who were older, presented with worse Killip class and higher GRACE risk score, less frequently underwent cardiac catheterization and revascularization. Furthermore, early use of evidence-based medications was

Conclusions

Despite current guidelines recommendations and a higher risk profile, ACS patients with prior CABG were less likely to receive evidence-based medical and invasive therapies. Conversely, patients with previous PCI are more likely to receive intensive medical and invasive therapies, compared to the CABG group. More definitive data from randomized controlled trials may help to guide the optimal treatment of these ACS patients. Furthermore, quality improvement measures to ensure proper

Acknowledgements

We thank all the study investigators, coordinators, and patients who participated in the Canadian ACS Registries I and II and GRACE and expanded-GRACE. Dr Andrew Yan is supported by the Canadian Institutes of Health Research and a New Investigator Award from the Heart and Stroke Foundation of Canada.

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Coronary Angiography and Revascularization Following Coronary Artery Bypass Grafting in British Columbia: Incidence, Predictors and Longer-term Outcomes
2018, Canadian Journal of Cardiology
Citation Excerpt :
In our cohort 18.1% of patients underwent diagnostic angiography following their index CABG, but only 46.5% of these patients underwent further revascularization. Previous studies have found that a history of CABG was an independent predictor of medical management alone following an ACS, whereas a history of PCI predicted a greater likelihood of undergoing angiography.8,9 In a real-world setting it seems the hazards of undertaking angiography and PCI in patients with previous CABG are perceived to outweigh the benefits in a significant number of cases.
Coronary artery bypass grafting (CABG) is established treatment for subsets of coronary artery disease (CAD). Observational data have characterised significant progression of native coronary as well as graft vessel disease during longer-term follow-up, potentially reducing the benefit of CABG. We sought to assess longer-term outcomes following CABG by determining rates of repeat coronary angiography, revascularization procedures, and survival.
Data for all patients undergoing isolated CABG in British Columbia between 2001 and 2009 inclusive, and with follow-up until the end of 2013, were retrieved from the British Columbia Cardiac Registry. Cox proportional hazard regression and competing risk regression were performed for survival and subsequent cardiac procedures (coronary angiography, percutaneous coronary intervention [PCI] or repeat CABG).
Data were available from 17,316 patients with a mean age at index CABG of 65.7 ± 9.8 years. At a median follow-up of 8.5 (range 4.0 to 12.9) years, 3185 patients (18.4%) had died, 3135 (18.1%) underwent repeat coronary angiography with or without PCI or repeat CABG, and 11,557 (66.7%) had survived without additional procedures. Of those who underwent angiography, 1459 patients (46.5%) underwent further revascularization. In multivariate analysis, the strongest predictors of long-term mortality were dialysis dependency and age >75, whereas left internal mammary artery utilization and aspirin therapy were protective. Repeat revascularization predicted survival (adjusted hazard ratio 0.76; 95% confidence interval, 0.63-0.92; P = 0.004), whereas angiography alone did not.
Following CABG, patients frequently undergo repeat coronary angiography. Although only a minority of patients receive further revascularization, this appears to be associated with longer-term survival.
Le pontage aortocoronarien (PAC) est le traitement de référence pour certains sous-ensembles de la maladie coronarienne. Les données d’observation recueillies durant le suivi à long terme ont mis en évidence une évolution marquée de la maladie coronarienne touchant tant l’artère native que le greffon qui pourrait atténuer les retombées positives d’une telle intervention. Nous avons cherché à évaluer les résultats à plus long terme du PAC en déterminant les taux de survie et de recours à l’angiographie coronarienne et à la revascularisation post-PAC.
Nous avons extrait du British Columbia Cardiac Registry les données se rapportant à l’ensemble des patients de Colombie-Britannique ayant subi un PAC isolé entre 2001 et 2009 inclusivement et ayant fait l’objet d’un suivi jusqu’à la fin de 2013. Les méthodes de régression à risques proportionnels de Cox et à risques concurrents ont été utilisées pour analyser les taux de survie et d’interventions cardiaques subséquentes (angiographie coronarienne, intervention coronarienne percutanée [ICP] ou nouveau PAC).
La recension a permis d’obtenir des données sur 17 316 patients dont l’âge moyen lors du PAC de référence était de 65,7 ± 9,8 ans. Après une période de suivi d’une durée médiane de 8,5 (intervalle de 4,0 à 12,9) ans, 3 185 patients (18,4 %) étaient décédés, 3 135 (18,1 %) avaient subi une nouvelle angiographie coronarienne avec ou sans ICP ou un nouveau PAC et 11 557 (66,7 %) avaient survécu sans intervention additionnelle. Dans le groupe ayant subi une angiographie, une revascularisation additionnelle chez 1 459 patients (46,5 %). Dans l’analyse multivariée, les variables prédictives les plus fortes de la mortalité à long terme étaient la dépendance à la dialyse et l’âge supérieur à 75 ans, tandis que l’utilisation de l’artère mammaire interne gauche et le traitement par l’aspirine avaient un effet protecteur. L’intervention de revascularisation additionnelle était un facteur prédictif de la survie (rapport des risques instantanés rajusté : 0,76; intervalle de confiance à 95 % : 0,63-0,92; p = 0,004), contrairement à l’angiographie seule.
À la suite d’un PAC, les patients subissent fréquemment une nouvelle angiographie coronarienne. Alors qu’une minorité seulement de patients subissent également une revascularisation, cette intervention semble être associée à la survie à plus long terme.
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Recent developments have highlighted the challenges facing cardiovascular clinical research in global contemporary practice, particularly in North America, including shifting priorities for drug development targets, increasing regulatory requirements, and expensive operational approaches for conducting randomized clinical trials. Nonetheless, emerging trends such as the consolidation of practices and hospitals into integrated health systems, the integration of electronic health records from thousands of practices into large data repositories to support prospective research studies, and streamlined operational approaches such as registry-based trials and risk-based monitoring have created numerous opportunities to disrupt the clinical research paradigm. Within this context, academic research organizations around the globe, particularly a strengthened collaboration of 3 established academic research organizations in North America, are uniquely positioned to promote and develop grassroots collaborations across all types of clinical practices, to delineate successful solutions to obstacles that limit clinical research initiatives, and to guide the future of cardiovascular research in the global research environment.
Outcomes of patients with prior coronary artery bypass grafting and acute coronary syndromes: Analysis from the acuity (Acute catheterization and urgent intervention triage strategy) trial
2012, JACC: Cardiovascular Interventions
Citation Excerpt :
In the Veterans Administration Cooperative Study of Coronary Artery Bypass Surgery, approximately 1 in 3 patients had an MI within 10 years after CABG (3). In recent ACS reports, 12% to 22% of patients had prior CABG (11–16). In ACUITY, in which nearly 14,000 patients with moderate- and high-risk ACS were enrolled from 450 sites from 17 countries, 18% of patients had previously undergone CABG, which is consistent with these recent reports.
This study sought to assess the contemporary outcomes of patients with prior coronary artery bypass graft (CABG) who present with moderate and high-risk acute coronary syndromes (ACS) and are treated with an early invasive strategy and contemporary antithrombin regimens.
The prognosis of patients with ACS and prior CABG in relation to triage strategy and contemporary antithrombotic regimens is unknown.
In the ACUITY (Acute Catheterization and Urgent Intervention Triage Strategy) trial, 2,475 of 13,764 patients (18.0%) with ACS managed with an early invasive strategy had previously undergone CABG. Their outcomes were examined according to treatment and randomized antithrombin regimen.
Prior CABG was associated with older age, more frequent comorbidities, higher Thrombolysis In Myocardial Infarction risk score, and lower left ventricular ejection fraction. Patients with versus without prior CABG were less likely to undergo (repeat) CABG and were more likely to be managed medically. At 1 year, patients with versus without prior CABG had higher rates of major adverse cardiac events (MACE) (22.5% vs. 15.2%, p < 0.0001) due to greater mortality (5.4% vs. 3.9%, p < 0.0001), myocardial infarction (10.0% vs. 6.8%, p < 0.0001), and unplanned revascularization (13.1% vs. 8.2%, p < 0.0001). History of CABG was an independent predictor of MACE. The 1-year MACE rates were not significantly different after randomization to bivalirudin versus heparin plus a glycoprotein IIb/IIIa inhibitor (odds ratio: 1.24, 95% confidence interval: 0.90 to 1.70).
Despite the progress in the treatment of coronary artery disease, patients with prior CABG and ACS have a poor prognosis, substantially worse than for those without prior CABG. Whereas bivalirudin monotherapy was an acceptable treatment for these patients, it did not improve their prognoses.
Temporal changes in the management and outcome of Canadian diabetic patients hospitalized for non-ST-elevation acute coronary syndromes
2011, American Heart Journal
Citation Excerpt :
To evaluate the independent prognostic significance of diabetes on in-hospital mortality, we performed multivariable analysis adjusting for the components of the GRACE risk score (a validated predictor of in-hospital mortality).19-21 We performed further multivariable analysis to evaluate the independent association between diabetes and in-hospital coronary angiography, adjusting for the components of the GRACE risk score, registry enrollment, gender, the presence of an on-site cardiac catheterization facility, previous MI, heart failure, percutaneous coronary intervention (PCI), or coronary artery bypass surgery (CABG).22-25 To control for the clustering of patients within hospitals, we used generalized estimating equations.
There are limited data on the contemporary management and outcomes of non–ST-elevation acute coronary syndrome (NSTE-ACS) patients with diabetes in the “real world.” We sought to evaluate (1) the temporal changes in the medical and invasive management and (2) in-hospital outcome of NSTE-ACS patients with and without diabetes.
We included Canadian patients hospitalized for NSTE-ACS enrolled in 4 consecutive, prospective, multicenter registries: Canadian ACS-I (n = 3259; 1999-2001), ACS-II (n = 1,956; 2002-2003), Global Registry of Acute Coronary Events (GRACE/GRACE2 [n = 7,561; 2004-2007]) and Canadian Registry of Acute Coronary Events (n = 1,326; 2008). Participants were stratified by the presence or absence of preexisting diabetes on admission. Temporal changes in patient management and outcomes were evaluated across the 4 registries. Multivariable analyses were performed to determine the independent prognostic significance of diabetes.
Of the 14,102 NSTE-ACS patients, 4,046 (28.7%) had previously diagnosed diabetes. Patients with diabetes were older; were more likely to have prior cardiac history including myocardial infarction, revascularization, and heart failure; and had worse Killip class and higher GRACE risk score (all P < .001). Over time, there were significant increases in the use of in-hospital coronary angiography and revascularization. However, diabetic patients were less likely to undergo coronary angiography (52.5% vs 57%, P < .001) or revascularization (28.4% vs 33.4%, P < .001). The underuse of invasive procedures in diabetic patients was seen in all registries and was persistent over time. Overall, compared with the group without diabetes, diabetic patients had higher unadjusted rates of in-hospital mortality (3.0% vs 1.6%, P < .001). In multivariable analysis adjusting for components of the GRACE risk score, diabetes remained an independent predictor of in-hospital death (adjusted odds ratio 1.66, 95% CI 1.30-2.11, P < .001).
Over the last decade, NSTE-ACS patients with diabetes continue to be treated more conservatively, despite evidence that they would derive similar or even greater benefits from aggressive treatment. This underutilization of evidence-based therapies among diabetic patients with NSTE-ACS in the “real world” may partly explain their worse outcome.
Revascularisation and outcomes after acute coronary syndromes in patients with prior coronary artery bypass grafting-ANZACS-QI 67
2022, New Zealand Medical Journal
Invasive versus medically managed acute coronary syndromes with prior bypass (CABG-ACS): Insights into the registry versus randomised trial populations
2021, Open Heart

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Clinical InvestigationAcute Ischemic Heart DiseaseManagement patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularization

Background

Methods

Results

Conclusions

Section snippets

Study design

Study population characteristics

Discussion

Conclusions

Acknowledgements

Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study. FRagmin and Fast Revascularisation during InStability in Coronary artery disease Investigators

Lancet

Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban

N Engl J Med

Interventional versus conservative treatment for patients with unstable angina or non-ST elevation myocardial infarction: the British Heart Foundation RITA 3 randomized trial. Randomized Intervention Trial of unstable Angina

Lancet

J Am Coll Cardiol

Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes

Am Heart J

Baseline characteristics, management practices, and in-hospital outcomes of patients hospitalized with acute coronary syndromes in the Global Registry of Acute Coronary Events (GRACE)

Am J Cardiol

Predictors of hospital mortality in the global registry of acute coronary events

Arch Intern Med

One-year outcome of patients after acute coronary syndromes (from the Canadian Acute Coronary Syndromes Registry)

Am J Cardiol

Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes

Arch Intern Med

Clinical trial–derived risk model may not generalize to real-world patients with acute coronary syndrome

Am Heart J

Risk scores for risk stratification in acute syndromes: useful but simpler is not necessarily better

Eur Heart J

The association between on-site cardiac catheterization facilities and the use of coronary angiography after acute myocardial infarction. Myocardial Infarction Triage and Intervention Project Investigators

N Engl J Med

Admission to hospitals with on-site cardiac catheterization facilities :impact on long-term costs and outcomes

Circulation

Utilization of early invasive management strategies for high-risk patients with non–ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative

JAMA

Clinical Investigation
Acute Ischemic Heart Disease
Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularization