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Background
Elderly (≥ 75 years) patients form a large sub-group of non–ST-segment elevation myocardial infarction (NSTEMI) population but are vastly under-represented in trials. Thus, the benefits of an early angiography in the elderly remain unclear. In this systematic review, we compared outcomes of “invasive” and “conservative” strategies of NSTEMI management in elderly patients.Methods
A comprehensive search of major databases was performed. We included comparative studies of any design that enrolled patients ≥ 75 years, and where outcomes of both strategies of NSTEMI management were available.Results
Among the included studies (3 randomized and 6 observational), there were 6340 patients in the “invasive” group and 13,358 patients in the “conservative” group. The 12-month mortality rate (odds ration [OR], 0.45; p < 0.00001), the 30-day mortality (OR, 0.50; p = 0.0009), and events of stroke (OR, 0.42; p < 0.00001) were significantly lower in the invasive group. Major bleeding was higher in the invasive cohort (OR, 1.63; p = 0.03). Analysis of randomised studies showed lower reinfarction with invasive approach at 12 months (p = 0.0001). Significant heterogeneity was noted among studies according to study design.Conclusion
The overall benefit with invasive strategy comes from the data of observational studies that are prone to selection bias. We believe that there is a need for a large randomized study in the elderly patients regarding management of NSTEMI. 相似文献10.
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Carolina Malta Hansen Tracy Y. Wang Anita Y. Chen Karen Chiswell Deepak L. Bhatt Jonathan R. Enriquez Timothy Henry Matthew T. Roe 《JACC: Cardiovascular Interventions》2018,11(4):369-380
Objectives
The study sought to characterize patient- and hospital-level variation in early angiography use among non–ST-segment elevation myocardial infarction (NSTEMI) patients.Background
Contemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described.Methods
The study analyzed NSTEMI patients included in ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012 to 2014) who underwent in-hospital angiography. Timing of angiography was categorized as early (≤24 h) vs. delayed (>24 h). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures.Results
A total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7% to 100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores.Conclusions
In contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence. 相似文献15.
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《JACC: Cardiovascular Interventions》2014,7(6):604-612
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