Unstable angina non ST elevation myocardial infarction initial conservative versus initial invasive strategies

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Overview of Initial Conservative versus Initial Invasive Strategies in UA / NSTEMI

Two approaches to the use of cardiac catheterization and revascularization in UA/NSTEMI include an early invasive strategy, involving routine early cardiac catheterization and revascularization with percutaneous coronary intervention (PCI) or coronary bypass grafting(CABG). The second one is a more conservative approach with initial medical management with catheterization and revascularization only for recurrent ischemia either at rest or on a noninvasive stress test. The objective of this is to provide a strategy that has the most potential to yield the best clinical outcome and improve long-term prognosis. Patients treated with an invasive strategy generally undergo coronary angiography within 4 to 48 h of admission. Some patients may also require urgent catheterization and revascularization in the absence of ST deviation because of ongoing ischemic symptoms or hemodynamic or rhythm instability. Such patients are not candidates for conservative strategy.

Trials supporting Initial Conservative Strategy

TIMI IIIB trial studied 1473 patients with unstable angina or NQMI were assigned to either tPA versus placebo and early invasive strategy versus conservative approach. The end point for the comparison of the two strategies (death, myocardial infarction, or an unsatisfactory symptom-limited exercise stress test at 6 weeks) occurred in 18.1% of patients assigned to the early conservative strategy and 16.2% of patients assigned to the early invasive strategy (P = NS). It concluded that both strategies can be used to achieve similar low mortality at the end of 6 weeks. However, it did show reduced incidence of days of hospitalization and of rehospitalization and in the use of antianginal drugs in early invasive strategy group.

VANQWISH trial randomly assigned 920 patients to either invasive management or conservative management, defined as medical therapy and noninvasive testing, with subsequent invasive management if indicated by the development of spontaneous or inducible ischemia, within 72 hours of the onset of a non-Q-wave infarction. Overall mortality during follow-up(one month and one year) did not differ significantly between patients assigned to the conservative-strategy group and those assigned to the invasive-strategy group.

Patients for whom a conservative approach is chosen should undergo a stress test(e.g., exercise or pharmacological stress) for the assessment of ischemia is recommended before discharge or shortly thereafter to identify patients who may also benefit from revascularization. Hence, a plan for noninvasive evaluation is required to detect severe ischemia that occurs spontaneously or at a low threshold of stress and to promptly refer these patients for coronary angiography and revascularization when possible. Also, early assessment of left ventricular function is recommended with an echocardiogram. In recent times, the use of aggressive anticoagulant and antiplatelet agents has reduced the incidence of adverse outcomes in patients managed conservatively.

Trials supporting Initial Invasive Strategy

More recently conducted randomized trials have shown benefit of early invasive strategy. FRISC II was a prospective randomized multicenter study conducted in 58 Scandinivian hospitals involving of 2457 patients with unstable [[CAD}]. Patients were assigned in an early invasive or non-invasive treatment strategy with placebo-controlled long-term low-molecular-mass heparin (dalteparin) for 3 months. Coronary angiography was done within the first 7 days in 96% and 10%, and revascularisation within the first 10 days in 71% and 9% of patients in the invasive and non-invasive groups, respectively. Patients were followed up at 6 months for composite endpoint of death or myocardial infarction. There was a significant decrease in myocardial infarction alone and non-significant reduction in mortality, independent of dalteparin treatment. Additional analyses showed greater benefit of the invasive strategy in higher risk groups identified by ST segment depression on the admission ECG or troponin elevation.

TACTICS-TIMI 18 trial enrolled 2220 patients with unstable angina and myocardial infarction without ST-segment elevation who had electrocardiographic evidence of changes in the ST segment or T wave, elevated levels of cardiac markers, a history of coronary artery disease, or all three findings. During follow up, the rate of death, MI, or rehospitalization for ACS at 6 months fell from 19.4 percent in the conservative group to 15.9 percent in the early invasive group. Death or nonfatal MI was significantly reduced at 30 days and at 6 months. Using the TIMI risk score, there was significant benefit of the early invasive strategy in intermediate(score 3 to 4) and high-risk patients (5 to 7); whereas low-risk (0 to 2) patients had similar outcomes when managed with either strategy. This study also showed, interestingly, that invasive approach was more cost effective.

ACC / AHA Guidelines (DO NOT EDIT)

“

Class I 1. An early invasive strategy (i.e., diagnostic coronary angiography with intent to perform percutaneous coronary revascularization or CABG) is indicated in UA / NSTEMI patients who have refractory angina or hemodynamic or electrical instability (without serious comorbidities or contraindications to such procedures). (Level of Evidence: B) 2. An early invasive strategy (i.e., diagnostic angiography with intent to perform percutaneous coronary revascularization or CABG) is indicated in initially stabilized UA / NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events (Level of Evidence: A) Class IIb 1. In initially stabilized patients: a. An initially conservative (i.e., a selectively invasive) strategy may be considered as a treatment strategy for UA / NSTEMI patients (without serious comorbidities or contraindications to such procedures) who have an elevated risk for clinical events including those who are troponin positive. (Level of Evidence: B) b. The decision to implement an initial conservative (vs. initial invasive) strategy in these patients may be made by considering physician and patient preference. (Level of Evidence: C) 2. An invasive strategy may be reasonable in patients with chronic renal insufficiency. (Level of Evidence: C) Class III 1. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) is not recommended in patients with extensive comorbidities (e.g., liver failure or pulmonary failure, cancer), in whom the risks of revascularization and comorbid conditions are likely to outweigh the benefits of revascularization. (Level of Evidence: C) 2. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) is not recommended in patients with acute chest pain and a low likelihood of Acute coronary syndromes. (Level of Evidence: C) 3. An early invasive strategy (i.e., diagnostic angiography with intent to perform coronary artery revascularization) should not be performed in patients who will not consent to revascularization regardless of the findings. (Level of Evidence: C)

”

See Also

• The UA / NSTEMI Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction