Hospital Patterns of Medical Management Strategy Use for Patients With Non–ST-Elevation Myocardial Infarction and 3-Vessel or Left Main Coronary Artery Disease

Ralf E. Harskamp, MD; Tracy Y. Wang, MD, MHS, MSc; Deepak L. Bhatt, MD, MPH; Stephen D. Wiviott, MD; Ezra A. Amsterdam, MD; Shuang Li, MS; Laine Thomas, PhD; Robbert J. de Winter, MD, PhD; Matthew T. Roe, MD, MHS

Disclosures

Am Heart J. 2014;167(3):355-362. 

In This Article

Abstract and Introduction

Abstract

Background Patients with non–ST-elevation myocardial infarction (NSTEMI) and three-vessel or left main coronary disease (3VD/LMD) have a high risk of long-term mortality when treated with a medical management strategy (MMS) compared with revascularization.

Methods We evaluated patterns of use and patient features across United States hospitals designated by MMS for NSTEMI patients with 3VD/LMD included in the ACTION Registry–GWTG from 2007–2012.

Results A total of 42,535 patients without prior bypass surgery were found to have 3VD (≥50% stenosis in all major coronary vessels) or LMD (≥50% lesion) during in-hospital angiography at 423 hospitals with percutaneous and surgical revascularization capabilities. Hospitals (n = 316) with an adequate volume (≥25 NSTEMI patients treated) were stratified into tertiles defined by use of MMS; differences in patient characteristics and outcomes were analyzed. The proportion of NSTEMI patients treated with MMS at all hospitals varied from 16% to 19% each quarter and did not change significantly from 2007 to 2012 (P trend = .11). Among hospitals with adequate volume, the proportion of patients treated with MMS also varied widely (median 17.1%, range: 0.0–44.8%, P < .0001). Patient baseline characteristics, predicted mortality risk, actual in-hospital mortality rates, and discharge treatments were similar across hospital tertiles.

Conclusions Close to 20% of patients with NSTEMI and 3VD/LMD identified during in-hospital angiography are treated with MMS without revascularization in contemporary practice. Since the use of MMS varies widely across hospitals despite a relatively similar hospital-level case mix, these findings suggest that there is no standard threshold for the use of revascularization in NSTEMI patients with 3VD/LMD.

Introduction

More than 1 million patients are admitted annually to hospitals in the United States (U.S.) with acute coronary syndrome (ACS). Approximately 75% of these ACS patients undergo coronary angiography, with one-third having multi-vessel coronary disease.[1–4] Although coronary artery bypass graft (CABG) surgery is typically recommended for patients with multi-vessel coronary artery disease (including those with left-main disease), other treatment options such as percutaneous coronary intervention (PCI) or a medical management strategy (MMS) are often utilized for patients with an unacceptably high peri-operative risk, or for those with angiographic features (such as poor target vessels) that preclude surgical revascularization.[5–8] Due to factors related to the index myocardial infarction (MI) event, the revascularization decision-making process for non–ST-elevation myocardial infarction (NSTEMI) patients with multi-vessel disease may differ from the decision-making process for patients with multi-vessel disease that is identified during elective angiography. Nevertheless, the American College of Cardiology/American Heart Association unstable angina (UA)/NSTEMI guidelines endorse a Class IA recommendation for revascularization in such patients.[9]

A recent analysis from a clinical trial database containing data from UA/NSTEMI patients with significant coronary disease identified during coronary angiography demonstrated that approximately 20% of these patients were medically managed without subsequent revascularization and that multi-vessel coronary disease was a strong factor associated with the use of MMS.[10,11] Another study demonstrated that the use of PCI versus CABG for UA/NSTEMI patients with multi-vessel disease treated in routine practice increased after the introduction of drug-eluting stents in 2003; however, this study did not evaluate the use of medical management, so contemporary patterns of revascularization for UA/NSTEMI patients with multi-vessel disease treated in routine practice remain poorly delineated.[4] Therefore, we utilized the National Cardiovascular Data Registry® (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry®–Get with the Guidelines™ (ACTION Registry–GWTG) database to characterize the contemporary utilization, temporal trends, and hospital-level variation of MMS versus revascularization for NSTEMI patients with three-vessel and/or left main coronary disease (3VD/LMD) identified during in-hospital angiography.

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