Case Brian C, Yerasi Charan, Wang Yanying, Forrestal Brian J, Hahm Joshua, Dolman Sarahfaye, Weintraub William S, Waksman Ron
Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, District of Columbia.
Georgetown University School of Medicine, Washington, District of Columbia.
Am J Cardiol. 2020 Nov 1;134:24-31. doi: 10.1016/j.amjcard.2020.08.010. Epub 2020 Aug 16.
Clinical trials have shown improved outcomes with an early invasive approach for non-ST-elevation myocardial infarction (NSTEMI). However, real-world data on clinical characteristics and outcomes based on time to revascularization are lacking. We aimed to analyze NSTEMI rates, revascularization timing, and mortality using the 2016 Nationwide Readmissions Database. We identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted. Our analysis included 748,463 weighted NSTEMI hospitalizations in 2016. Of these hospitalizations, 50.3% (376,695) involved diagnostic angiography, with 34.1% (255,199) revascularized. Of revascularized patients, 77.6% (197,945) underwent PCI and 22.4% (57,254) underwent CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission (32.9%; 65,155). This differs from CABG, which was most commonly performed on day 3 after admission (13.7%; 7,823). The in-hospital mortality rate increased after day 1 for PCI patients and after day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed. Our study shows that patients undergoing early revascularization differ from those undergoing later revascularization. Mortality is generally high with delayed revascularization, as these are sicker patients. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.
临床试验表明，对于非ST段抬高型心肌梗死（NSTEMI）采用早期侵入性治疗方法可改善预后。然而，缺乏基于血运重建时间的临床特征和预后的真实世界数据。我们旨在使用2016年全国再入院数据库分析NSTEMI发病率、血运重建时间和死亡率。我们确定了接受诊断性血管造影并随后接受经皮冠状动脉介入治疗（PCI）或冠状动脉旁路移植术（CABG）的患者。最后，提取了血运重建时间和死亡率（住院期间和30天）。我们的分析纳入了2016年748,463例加权的NSTEMI住院病例。在这些住院病例中，50.3%（376,695例）进行了诊断性血管造影，其中34.1%（255,199例）进行了血运重建。在接受血运重建的患者中，77.6%（197,945例）接受了PCI，22.4%（57,254例）接受了CABG。合并症较多的患者血运重建往往更延迟。PCI最常在入院当天进行（32.9%；65,155例）。这与CABG不同，CABG最常在入院后第3天进行（13.7%；7,823例）。PCI患者在入院第1天后住院死亡率增加，CABG患者在入院第4天后住院死亡率增加，而随着血运重建延迟，这两类人群的30天住院死亡率均增加。我们的研究表明，早期接受血运重建的患者与晚期接受血运重建的患者不同。由于这些患者病情较重，延迟血运重建时死亡率通常较高。需要进行随机临床试验来评估极早期血运重建（<90分钟）是否与高危患者的长期预后改善相关。
