Tricoci Pierluigi, Lokhnygina Yuliya, Berdan Lisa G, Steinhubl Steven R, Gulba Dietrich C, White Harvey D, Kleiman Neal S, Aylward Philip E, Langer Anatoly, Califf Robert M, Ferguson James J, Antman Elliott M, Newby L Kristin, Harrington Robert A, Goodman Shaun G, Mahaffey Kenneth W
Duke Clinical Research Institute, 2400 Pratt St, Room 0311 Terrace Level, Durham, NC 27705, USA.
Circulation. 2007 Dec 4;116(23):2669-77. doi: 10.1161/CIRCULATIONAHA.107.690081. Epub 2007 Nov 19.
Optimal timing for an early invasive strategy in patients with non-ST-segment-elevation acute coronary syndrome remains unclear. We evaluated the relationship between time from hospital admission to coronary angiography and outcomes in high-risk patients with non-ST-segment-elevation acute coronary syndrome who underwent angiography within 48 hours of admission.
Data from 10 027 patients enrolled in the Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors (SYNERGY) trial were analyzed. Patients were grouped by 6-hour intervals of time from hospital admission to coronary angiography. Primary outcomes were 30-day death or myocardial infarction, in-hospital Thrombolysis In Myocardial Infarction (TIMI) and Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO) major bleeding, and blood transfusion. Adjusted estimates of event rates were obtained by use of a multivariable methodology that included possible confounders through baseline and accounted for propensity of time to angiography. The landmark method was used to calculate odds ratios and 95% confidence intervals of outcomes for each time period adjusted for baseline and postbaseline clinical events. Overall, 9216 patients (92%) underwent angiography, 6352 (63%) within 48 hours. Unadjusted and adjusted rates of death/myocardial infarction increased with increasing time to angiography. The adjusted odds ratio for death/myocardial infarction in patients receiving angiography in <6 hours was 0.56 (95% confidence interval 0.41 to 0.74), whereas after 30 hours, there was no significant benefit compared with further delayed angiography. Major bleeding and transfusion did not vary significantly across time-to-angiography intervals.
A decrease in the time to coronary angiography was associated with fewer ischemic outcomes and no increase in bleeding. Randomized clinical trials are needed to provide definitive evidence on optimal timing of coronary angiography but are difficult to design and conduct. Ongoing trials should instead clarify whether delaying angiography to administer aggressive upstream antithrombotic therapies is effective in the current setting of non-ST-segment-elevation acute coronary syndrome management.
非ST段抬高型急性冠状动脉综合征患者早期侵入性策略的最佳时机仍不明确。我们评估了从入院到冠状动脉造影的时间与入院后48小时内行冠状动脉造影的高危非ST段抬高型急性冠状动脉综合征患者预后之间的关系。
分析了纳入依诺肝素、血运重建和糖蛋白IIb/IIIa抑制剂新策略的卓越疗效（SYNERGY）试验的10027例患者的数据。根据从入院到冠状动脉造影的时间间隔6小时对患者进行分组。主要结局为30天死亡或心肌梗死、院内心肌梗死溶栓（TIMI）和全球应用链激酶及组织型纤溶酶原激活剂治疗冠状动脉闭塞（GUSTO）大出血以及输血。事件发生率的校正估计值通过多变量方法获得，该方法包括通过基线纳入可能的混杂因素，并考虑到造影时间的倾向。采用地标法计算每个时间段经基线和基线后临床事件校正的结局的比值比和95%置信区间。总体而言，9216例患者（92%）接受了冠状动脉造影，其中6352例（63%）在48小时内进行。未校正和校正的死亡/心肌梗死发生率随造影时间延长而增加。在<6小时内行冠状动脉造影的患者中，死亡/心肌梗死的校正比值比为0.56（95%置信区间0.41至0.74），而在30小时后，与进一步延迟造影相比，无显著获益。大出血和输血在造影时间间隔内无显著差异。
冠状动脉造影时间缩短与缺血性结局减少相关且出血无增加。需要进行随机临床试验以提供关于冠状动脉造影最佳时机的确切证据，但难以设计和实施。正在进行的试验应明确在当前非ST段抬高型急性冠状动脉综合征管理背景下，延迟造影以给予积极的上游抗栓治疗是否有效。
