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Background Previous trials suggest lower long-term risk of mortality after invasive rather than non-invasive management of patients with non-ST elevation myocardial infarction (NSTEMI), but the trials excluded very elderly patients. We aimed to estimate the effect of invasive versus non-invasive management within 3 days of peak troponin concentration on the survival of patients aged 80 years or older with NSTEMI. Methods Routine clinical data for this study were obtained from five collaborating hospitals hosting NIHR Biomedical Research Centres in the UK (all tertiary centres with emergency departments). Eligible patients were 80 years old or older when they underwent troponin measurements and were diagnosed with NSTEMI between 2010 (2008 for University College Hospital) and 2017. Propensity scores (patients' estimated probability of receiving invasive management) based on pretreatment variables were derived using logistic regression; patients with high probabilities of non-invasive or invasive management were excluded. Patients who died within 3 days of peak troponin concentration without receiving invasive management were assigned to the invasive or non-invasive management groups based on their propensity scores, to mitigate immortal time bias. We estimated mortality hazard ratios comparing invasive with non-invasive management, and compared the rate of hospital admissions for heart failure. Findings Of the 1976 patients with NSTEMI, 101 died within 3 days of their peak troponin concentration and 375 were excluded because of extreme propensity scores. The remaining 1500 patients had a median age of 86 (IQR 82–89) years of whom (845 [56%] received non-invasive management. During median follow-up of 3·0 (IQR 1·2–4·8) years, 613 (41%) patients died. The adjusted cumulative 5-year mortality was 36% in the invasive management group and 55% in the non-invasive management group (adjusted hazard ratio 0·68, 95% CI 0·55–0·84). Invasive management was associated with lower incidence of hospital admissions for heart failure (adjusted rate ratio compared with non-invasive management 0·67, 95% CI 0·48–0·93). Interpretation The survival advantage of invasive compared with non-invasive management appears to extend to patients with NSTEMI who are aged 80 years or older. Funding NIHR Imperial Biomedical Research Centre, as part of the NIHR Health Informatics Collaborative.

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.

Background Stenting-induced edge dissections (ED) can be assessed in detail by optical coherence tomography (OCT). This study sought to investigate the incidence, morphological characteristics, and spontaneous healing course of OCT-identified EDs following drug-eluting stent (DES) implantation in a non-ST segment elevation myocardial infarction (NSTEMI) patient-population. Methods Acute vessel wall injury at the 5-mm stent adjacent distal and proximal reference segments was assessed by post-procedure OCT and intravascular ultrasound (IVUS) in n = 97 NSTEMI-patients (n = 97 lesions). Six months OCT follow-up was available in 82 patients (including 35 untreated post-procedure EDs). Results The overall incidence of post-procedure OCT-detected ED was 38 per 97 patients (39.2%), and 47 per 182 stent edges (25.8%). None of the EDs were angiographically visualizable, while 10 (21.3%) were visible on concomitant IVUS-analysis. Morphologically, there was a significant difference in plaque type present at ED-edges vs. non-ED-edges when assessed with OCT; (1) lipid-rich and calcified plaques: 80.9% vs. 57.0%, (2) fibrous plaques: 17.0% vs. 26.7%, and (3) normal coronary vessels: 2.1% vs. 16.3%, p