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ObjectivesEarly access to invasive coronary angiography and revascularisation for high-risk non-ST elevation myocardial infarction (NSTEMI) improves outcomes and is supported by current guidelines. We sought to determine the most effective criteria at presentation to emergency department (ED) to identify high-risk NSTEMI.SettingSecondary care centre northwest England with national follow-up.Participants1642 consecutive patients (median age 59, 52% male) presenting to ED with a primary symptom of chest pain in whom there is suspicion of NSTEMI.Primary and secondary measuresMultivariate logistic regression analysis for the prediction of all-cause death (primary) and major adverse cardiac event (MACE defined as all-cause death, unplanned coronary revascularisation and adjudicated NSTEMI (third universal definition)) (secondary measure) at 1 year.ResultsThe incidence of adjudicated NSTEMI was 10.7%, and 1-year mortality was 6.3%. Independent predictors for all-cause death at 1 year were Global Registry of Acute Coronary Events (GRACE) >140, age (per decade increase) and high-sensitive cardiac troponin T (hs-cTnT) >50 ng/L. hs-cTnT >50 ng/L was associated with adjudicated index presentation NSTEMI in the greatest proportion of patients (61.7%). When using MACE at 12 months, as opposed to all-cause death, as an end point History, ECG, Age, Risk factors and Troponin (HEART) score ≥7 was included in the multivariate model and had better prediction of index NSTEMI than GRACE>140. Combining hs-cTnT >50 ng/L and a second independent predictor identified both a high proportion of index NSTEMI and elevated risk of all-cause death at 1 year.Conclusionshs-cTnT >50 ng/L or HEART score ≥7 appear effective strategies to identify high-risk NSTEMI at presentation to emergency room with chest pain. Multicentre prospective studies enriched with early presenters, and with competitor high-sensitive and point-of-care troponins, are required to validate and extend these findings.Trial registration numberNCT02581540.

Introduction Les dernieres recommandations des societes europeennes et americaines de cardiologie preconisent de realiser une coronarographie dans les 24 heures suivant l’admission des patients hospitalises pour un infarctus du myocarde sans sus-decalage du segment ST (NSTEMI). Recemment, l'etude VERDICT a objective une diminution d’evenements cardiovasculaires chez les patients ayant beneficie d’une coronarographie dans les 12 heures suivant leur admission pour un NSTEMI par rapport a un delai de 48-72 heures. Nous avons souhaite evaluer si realiser une coronarographie dans les 12 premieres heures etait benefique par rapport a la realiser dans les 12 a 24 premieres heures. Methodes Les donnees des patients hospitalises pour un NSTEMI entre 2009 et 2017 ont ete extraites du registre SPUM-ACS incluant de patients hospitalises avec un syndrome coronarien aigu dans quatre hopitaux universitaires en Suisse. Des modeles de Cox ont evalue l'association entre le timing de coronarographie et la survenue des evenements cardiovasculaires majeurs a un an (mortalite cardiovasculaire, infarctus du myocarde et accident vasculaire cerebral). Resultats Parmi 2’672 patients hospitalises pour un NSTEMI, 1’832 remplissaient les criteres d'inclusion. Parmi eux, 1’464 patients ont beneficie d’une coronarographie dans les 12 heures (groupe 12h) et 368 patients entre 12 and 24 heures (groupe 12-24h). Le fait d’avoir ete hospitalise durant une nuit ou un week-end a ete identifie par regression multivariee comme le seul facteur associe a la realisation d’une coronarographie plus tardivement. Apres la realisation d’un matching 2:1 par score de propension pour corriger les differences significatives entre les groupes (736 patients dans le groupe 12h et 368 patients dans le groupe 12-24h), aucune difference statistiquement significative en ce qui concerne le taux d’evenements cardiovasculaire a un an n’a ete mis en evidence (7.7% vs. 7.3%, HR : 1.050, 95% CI 0.637- 1.733, p=0.847). En outre, meme apres stratification par score de GRACE (>140 vs. ≤140), aucune reduction significative des evenements cardiovasculaires n’a ete mise en evidence chez les patients a haut-risque dans le groupe 12h (p for interaction=0.601). Conclusion Notre etude demontre que dans une cohorte de patients « real world » hospitalises pour un NSTEMI, la realisation d’une coronarographie dans les 12 heures suivant l’hospitalisation n’est pas associee avec une reduction des evenements cardiovasculaires par rapport a la realisation d’une coronarographie entre 12 et 24 heures suivant l’hospitalisation, meme chez les patients a haut risque (score de GRACE >140). -- Objective. To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI). Background. Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission. Methods. NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke). Results. Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12–24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12–24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637–1.733, p 0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p for interaction 0.601). Conclusions. In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved o ear cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients.