Real-world outcomes of early versus delayed PCI in NSTE-ACS patients: insights from the Netherlands Heart Registration

Background/ Introduction Despite advancements in the treatment of acute coronary syndromes, patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) continue to experience significant morbidity and mortality. Current guidelines recommend early invasive management in high-risk NSTE-ACS patients. However, real-world data evaluating the effectiveness of early (≤24 hours) versus delayed (>24 hours) percutaneous coronary intervention (PCI), particularly in elderly patients, remains limited. Purpose To address this gap, we evaluated the difference in mortality among NSTE-ACS patients undergoing early PCI (≤24 hours from hospital admission) versus delayed PCI (>24 hours), with a specific focus on those aged ≥75 years. Methods This retrospective observational cohort used prospectively collected data from the Netherlands Heart Registration and Dutch Hospital Data, including all NSTE-ACS patients who underwent PCI between 2018 and 2023. Results A total of 67,575 patients with complete follow-up were included. Early PCI was performed in 55% of the patients. Compared with delayed PCI, these patients were younger (67 versus 71 years) and had fewer comorbidities (higher eGFR, lower prevalence of diabetes, multivessel disease, prior myocardial infarction, PCI, and coronary bypass surgery). Early PCI was associated with a nonsignificant reduction in 30-day all-cause mortality in multivariable Cox regression (HR 0.88, 95% CI 0.77–1.01, p = 0.08) and in inverse probability of treatment weighting (IPTW-) weighted models (HR 0.88, 95% CI 0.76–1.01, p = 0.06). For 1-year all-cause mortality, early PCI was associated with lower mortality than delayed PCI in both multivariable Cox regression (HR 0.81, 95% CI 0.75–0.87, p<0.001) and IPTW-weighted models (HR 0.81, 95% CI 0.76–0.87, p<0.001). When stratified by age, early PCI conferred a clear survival benefit in patients <75 years (30-day mortality: HR 0.66, 95% CI 0.52–0.82, p < 0.001; 1-year mortality: HR 0.67, 95% CI 0.60–0.74, p < 0.001), whereas no meaningful benefit was observed in those ≥75 years (30-day mortality: HR 1.09, 95% CI 0.91–1.30, p = 0.35; 1-year mortality: HR 0.94, 95% CI 0.85–1.02, p = 0.16). Interaction terms between PCI timing and age group were statistically significant for both 30-day and 1-year mortality. Conclusions In this Dutch cohort, early PCI was associated with a significant reduction in 1-year mortality compared with delayed PCI, whereas the 30-day mortality benefit was less pronounced and not statistically significant. This mortality reduction was consistently observed in patients <75 years, in whom early PCI conferred a substantial survival advantage at both 30-day and 1-year follow-up. In contrast, among patients ≥75 years, early PCI did not significantly reduce mortality, underscoring the need for age-tailored timing strategies in invasive management.