August 17, 2004Open Access
View Full PaperAssociation of revascularisation with low mortality in non-ST elevation acute coronary syndrome, a report from GUSTO IV-ACS
Structured PICO
Does coronary revascularisation within 30 days reduce one-year mortality in patients with non-ST elevation acute coronary syndrome?
P
Population
7,496 patients with non-ST elevation acute coronary syndrome (documented by elevated cardiac troponin or transient/persistent ST-segment depression) who survived at least 30 days.
I
Intervention
Coronary revascularisation (CABG, PCI, or both) within 30 days.
C
Comparator
Medical treatment without revascularisation within 30 days.
O
Outcome
One-year mortality.hard clinical
Revascularisation within 30 days in patients with non-ST elevation acute coronary syndrome is associated with significantly improved one-year survival compared to medical therapy alone.
Abstract
BACKGROUND: Immediate, as well as early, revascularisation is of benefit in patients with acute coronary syndromes (ACS) presenting with ST elevation. However, trials comparing invasive versus medical treatment in patients with an acute coronary syndrome without ST elevation do not consistently show improvement in survival after revascularisation. Accordingly, additional data are warranted. METHODS: The effect of revascularisation within 30 days on one-year survival in the GUSTO IV ACS trial was investigated. A total of 7800 patients were included with an acute coronary syndrome without ST elevation, documented by either elevated cardiac troponin or transient or persistent ST-segment depression. In this trial, comparing abciximab versus placebo as initial medical therapy, coronary angiography within 60 h after randomisation was discouraged. In 30-day survivors, those who underwent revascularisation were compared with 30-day survivors without revascularisation. Adjustments were made for patient characteristics, and for a propensity score that was adjusted for covariates associated with the likelihood of early revascularisation. FINDINGS: Of the 7496 patients who survived at least 30 days, 2265 (30%) underwent coronary revascularisation within 30 days: 789 patients CABG, 1450 PCI and 26 both CABG and PCI. Procedure-related mortality was low at 1.8%. Patients with revascularisation had a lower one-year mortality compared to medically treated patients (2.3% vs. 5.6%, p < 0.001). After multivariable analyses, patients with revascularisation had a relative risk of subsequent mortality within 1 year of 0.53 (95% CI 0.37-0.77) compared to patients without revascularisation. CONCLUSIONS: Revascularisation within 30 days is associated with an improved prognosis in ACS without ST-segment elevation. The relative high mortality in medically treated patients may be related in part to patient selection, but warrants further studies to improve outcome of these patients.