title: Delay to angiography and outcomes following presentation with high-risk, non-ST-elevation acute coronary syndromes: results from the Global Registry of Acute Coronary Events.
abstract: OBJECTIVE
  To test if delay-to-angiography (>72 hours from admission) in patients presenting with high-risk non-ST-elevation acute coronary syndromes (NSTE-ACS) is associated with adverse outcomes.
  
  
  METHODS
  GRACE (Global Registry of Acute Coronary Events) is a multinational registry of patients admitted with NSTE-ACS.
  
  
  METHODS
  14 countries with varying healthcare systems.
  
  
  METHODS
  23 396 high-risk NSTE-ACS patients with complete initial data collection entered into GRACE between 1999 and 2006 were analysed.
  
  
  METHODS
  Data were analysed according to delay-to-angiography and subsequent in-hospital or post-discharge adverse outcomes.
  
  
  METHODS
  Outcomes recorded included death, myocardial infarction, recurrent ischaemia, stroke, new heart failure and composite major adverse cardiovascular event (MACE) comprising death, cerebrovascular accident and myocardial infarction. Revascularisation procedures were recorded.
  
  
  RESULTS
  10 089 (43.1%) had no in-hospital angiography. Median delay-to-angiography was 46 hours; 3680 (34%) patients waited >72 hours. 9.3% waited >7 days before angiography. Patients waiting longest were more often older, diabetic, women and had a history of heart failure, previous myocardial infarction or hypertension. Recurrent in-hospital ischaemia (33% vs 22%), reinfarction (8.4% vs 5.0%) and heart failure (14% vs 9.1%) were more common with delayed angiography. Delayed angiography was associated with better outcomes than no angiography (MACE 18.9% vs 22.2%, p = 0.015). MACE rates within six months of admission were higher with longer delay-to-angiography and highest of all with no angiography.
  
  
  CONCLUSIONS
  High-risk NSTE-ACS is suboptimally managed with 43% not undergoing angiography. One-third of those undergoing angiography are delayed >72 hours. Longer delays were more likely with higher risk, sicker patients. These delays were associated with adverse outcomes at six months. Very long delay was associated with lower MACE, but not mortality, compared to conservative management.
authors.affiliation: Waikato Hospital, Hamilton, New Zealand. neil.swanson@stees.nhs.uk
authors.forename: N
authors.initials: N
authors.lastname: Swanson
authors.forename: G
authors.initials: G
authors.lastname: Montalescot
authors.forename: K A
authors.initials: KA
authors.lastname: Eagle
authors.forename: S G
authors.initials: SG
authors.lastname: Goodman
authors.forename: W
authors.initials: W
authors.lastname: Huang
authors.forename: D
authors.initials: D
authors.lastname: Brieger
authors.forename: G
authors.initials: G
authors.lastname: Devlin
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D010818:Practice Patterns, Physicians'; D011379:Prognosis; D011446:Prospective Studies; D011787:Quality of Health Care; D011859:Radiography; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome