What is the efficacy of percutaneous coronary intervention (PCI) in the treatment of NSTE-ACS?

Updated: Nov 27, 2019
  • Author: George A Stouffer, III, MD; Chief Editor: Karlheinz Peter, MD, PhD  more...
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Answer

In terms of outcome data, several studies have assessed the use of an ischemia-guided strategy against the use of an early invasive strategy of revascularization

The VANQWISH (Veterans Affairs Non–Q-Wave Infarction Strategies in Hospital) trial compared an invasive strategy with conservative medical treatment in patients with non–Q-wave MI and found that the rates of death or nonfatal MI were higher in the invasive strategy group than in the conservative strategy group before hospital discharge, at 1 month, and at 1 year. [39]

Criticisms of this study include the exclusion of patients at very high risk; the lack of current aggressive medical therapies; a high rate of crossover to angiography in the conservative arm; a higher surgical mortality than expected in view of with contemporary standards; and the observation that most of the complications at 30 days occurred in patients who underwent CABG, with very few occurring in those who underwent balloon angioplasty. [39]

In contrast to the VANQWISH trial, four randomized studies found that an early invasive approach in patients with ACS was associated with improved outcomes.

The TIMI IIIb study showed less ischemia, shorter hospital stays, fewer readmissions, and fewer symptoms in patients treated by an early invasive approach. [40]

The FRISC (Fragmin and Fast Revascularization during Instability in Coronary Artery Disease) II trial prospectively randomized 2457 patients to receive either early invasive treatment with intracoronary stenting or noninvasive treatment and found that at 6 months, the composite endpoint of death or MI was higher in the latter arm than in the former. [41] Additionally, symptoms of angina and hospital readmissions were twice as common in the noninvasive arm as in the invasive arm.

The RITA-III study reported improved outcomes with early invasive therapy in 1810 patients at 5 years’ follow-up. [42] There was a statistically significant difference favoring an interventional strategy over conservative therapy with respect to all-cause mortality (15.1% vs 12.1%) and the rate of cardiac death or MI (15.9% vs 12.2%).

Data from the TACTICS-TIMI (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy–Thrombolysis in Myocardial Infarction) 18 trial showed that the primary endpoint of death, MI, or rehospitalization at 6 months occurred in 19.4% of the conservative group and 15.9% of the invasive group, with death or MI occurring in 9.5% and 7.3%, respectively. [43]

In this study, patients who had a positive troponin test result, those who had ST-segment changes, those who were older than 65 years, and, especially, those who were women with elevated brain natriuretic peptide (BNP) and C-reactive protein (CRP) levels derived particular benefit from an early invasive strategy. [43]

The ICTUS (Early Invasive versus Selectively Invasive Management for Acute Coronary Syndromes) trial, which compared an early invasive strategy (angiography and revascularization within 48 hours) with a selective invasive strategy (medical stabilization with angiography and revascularization in refractory cases) in 1200 Dutch patients, demonstrated no statistical difference in mortality or the composite endpoint (death, nonfatal MI, or rehospitalization for anginal symptoms within 1 year). [44]

At 3 years’ follow-up, the ICTUS trial documented a trend toward significance favoring the selective invasive strategy for the combined endpoints (30% early invasive vs 26% selective invasive) but reported no differences in all-cause mortality and cardiac death. Overall, the weight of evidence has favored early invasive therapy over the ischemia-guided strategy, with one collaborative meta-analysis of randomized trials showing an 18% relative reduction in death or MI. [45] The invasive arm was also associated with less angina and fewer hospitalizations.

In a meta-analysis of patient-level data from FRISC, ICTUS, and RITA trials, 14.7% of patients treated according to the early invasive strategy had cardiovascular death or nonfatal MI, versus 17.9% in the selective invasive group. [46] Absolute risk reduction of cardiovascular death and nonfatal MI was 2-3.8 % in the low-to-intermediate group and 11.1% in the highest-risk patient.

With respect to the timing of the invasive strategy, some studies have demonstrated the benefit of early angiography, [47] particularly in high-risk patients (GRACE >140). A more delayed strategy is reasonable in low-to-intermediate risk patients. Two meta-analyses showed that whereas the early invasive approach yields no survival benefit or reduction in recurrent MI or major bleeding rates, it also poses no early hazard and has the advantages of less recurrent ischemia and a shorter hospital stay. [48, 49]


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