Bueno Héctor, Pocock Stuart, Medina Jesús, Danchin Nicolas, Annemans Lieven, Licour Muriel, Gregson John, Vega Ana María, van de Werf Frans
Grupo de Investigación Multidisciplinar Traslacional, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Rev Esp Cardiol (Engl Ed). 2017 Oct;70(10):817-824. doi: 10.1016/j.rec.2016.12.031. Epub 2017 Mar 11.
A large proportion of patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis.
Patient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality.
Medical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P < .001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR = 1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR = 1.90; 95%CI, 1.23-2.95) compared with revascularized patients.
Medically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population.
大部分非ST段抬高型急性冠状动脉综合征（NSTEACS）患者最初选择药物治疗（MM），在首次发病期间或之后未接受冠状动脉血运重建治疗。本研究旨在探讨NSTEACS患者选择MM的临床路径及其对预后的影响。
在欧洲和拉丁美洲20个国家555家医院纳入的5591例NSTEACS患者的前瞻性队列中，记录患者特征、选择MM的路径以及2年结局。采用Cox模型评估医院管理对出院后死亡率的影响。
2306例（41.2%）患者选择了药物治疗，其中669例（29%）患有严重冠状动脉疾病（CAD），451例（19.6%）患有非严重疾病，1186例（51.4%）未接受冠状动脉造影。接受药物治疗的患者比接受血运重建治疗的患者年龄更大，风险特征更高。接受药物治疗的患者2年死亡率高于接受血运重建治疗的患者（11.0%对4.4%；P <.001），未接受造影的患者（14.6%）和患有严重CAD的患者（9.3%）死亡率更高。与接受血运重建治疗的患者相比，未接受造影的患者（HR = 1.81；95%CI，1.23 - 2.65）或患有严重CAD但未接受血运重建治疗的患者（HR = 1.90；95%CI，1.23 - 2.95）风险调整后的死亡率最高。
接受药物治疗的NSTEACS患者是一个异质性群体，具有不同的风险特征和结局。在设计该人群的未来研究时应考虑这些差异。
