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Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Authors :
Ilan Raymond
Kari Saunamäki
Thomas Engstrøm
Peter Clemmensen
Erik Jørgensen
Ole Peter Kristiansen
Dan Eik Høfsten
Hanne Elming
Jan Skov Jensen
Olav W. Nielsen
Henning Kelbæk
Jens D. Hove
Jan Bech
Søren Galatius
Rolf Steffensen
Gunnar Gislason
Klaus F. Kofoed
Merete Heitmann
Lene Kløvgaard
Maria Helena Dominguez Vall-Lamora
Lars Køber
Gitte G. Fornitz
Ulrik Abildgaard
Charlotte Kragelund
Ida Hastrup Svendsen
Stig Lyngbæk
Lene Holmvang
Steffen Helqvist
Birgit Jurlander
Lia Bang
Peter Riis Hansen
Christian Torp-Pedersen
Susette K. Therkelsen
Frants Pedersen
Jesper J. Linde
Tem Jørgensen
Thomas Fritz Hansen
Jawdat Abdulla
Source :
Kofoed, K F, Kelbæk, H, Hansen, P R, Torp-Pedersen, C, Høfsten, D, Kløvgaard, L, Holmvang, L, Helqvist, S, Jørgensen, E, Galatius, S, Pedersen, F, Bang, L, Saunamaki, K, Clemmensen, P, Linde, J J, Heitmann, M, Wendelboe Nielsen, O, Raymond, I E, Kristiansen, O P, Svendsen, I H, Bech, J, Dominguez Vall-Lamora, M H, Kragelund, C, Hansen, T F, Dahlgaard Hove, J, Jørgensen, T, Fornitz, G G, Steffensen, R, Jurlander, B, Abdulla, J, Lyngbæk, S, Elming, H, Therkelsen, S K, Abildgaard, U, Jensen, J S, Gislason, G, Køber, L V & Engstrøm, T 2018, ' Early versus standard care invasive examination and treatment of patients with non-ST-segment elevation acute coronary syndrome : VERDICT Randomized Controlled Trial ', Circulation, vol. 138, no. 24, pp. 2741-2750 . https://doi.org/10.1161/CIRCULATIONAHA.118.037152, Kofoed, K F, Kelbæk, H, Riis Hansen, P, Torp-Pedersen, C, Høfsten, D, Kløvgaard, L, Holmvang, L, Helqvist, S, Jørgensen, E, Galatius, S, Pedersen, F, Bang, L, Saunamaki, K, Clemmensen, P, Linde, J J, Heitmann, M, Wendelboe Nielsen, O, Raymond, I E, Peter Kristiansen, O, Hastrup Svendsen, I, Bech, J, Dominguez Vall-Lamora, M H, Kragelund, C, Fritz Hansen, T, Dahlgaard Hove, J, Jørgensen, T, Fornitz, G G, Steffensen, R, Jurlander, B, Abdulla, J, Lyngbæk, S, Elming, H, Krohn Therkelsen, S, Abildgaard, U, Skov Jensen, J, Gislason, G, Køber, L V & Engstrøm, T 2018, ' Early versus standard care invasive examination and treatment of patients with non-ST-segment elevation acute coronary syndrome : verdict randomized controlled trial ', Circulation, vol. 138, no. 24, pp. 2741-2750 . https://doi.org/10.1161/CIRCULATIONAHA.118.037152
Publication Year :
2018
Publisher :
Ovid Technologies (Wolters Kluwer Health), 2018.

Abstract

Background: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. Methods: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) ( ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. Results: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1–4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78–1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67–1.01; P value for interaction=0.023). Conclusions: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02061891.

Details

ISSN :
15244539 and 00097322
Volume :
138
Database :
OpenAIRE
Journal :
Circulation
Accession number :
edsair.doi.dedup.....4f3372479a0e32f4d8b2b0621f59e106
Full Text :
https://doi.org/10.1161/circulationaha.118.037152