Clinical and angiographic predictors of short- and long-term ischemic events in acute coronary syndromes: results from the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial.
BACKGROUND
Contemporary adjunctive pharmacology and revascularization strategies have improved the prognosis of patients with acute coronary syndromes (ACSs). We sought to identify the clinical and angiographic predictors of cardiac ischemic events in patients with ACSs treated with an early invasive strategy.


RESULTS
Multivariable logistic regression was used to analyze the relation between baseline characteristics and 30-day and 1-year composite ischemia (death, myocardial infarction, or unplanned revascularization) among the 6921 ACS patients included in the prespecified angiographic substudy of the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial. Of the 6921 patients, 3826 (55.3%) were treated with percutaneous coronary intervention, 755 (10.9%) with coronary artery bypass grafting, and 2340 (33.8%) with medical therapy. Composite ischemia occurred in 595 (8.6%) patients at 30 days and in 1153 (17.4%) at 1 year. Renal insufficiency, biomarker elevation, ST-segment deviation, nonuse of aspirin or thienopyridine, insulin-treated diabetes, older age, baseline lower hemoglobin value, history of percutaneous coronary intervention, and current smoking were independently associated with 30-day or 1-year ischemic events. Angiographic characteristics predicting ischemic events included number of diseased vessels, moderate/severe calcification, worst percent diameter stenosis, jeopardy score, lower left ventricular ejection fraction, lesion eccentricity, and thrombus. With use of receiver operating characteristic methodology, the c statistic improved for the predictive model by adding angiographic to clinical parameters for the 30-day composite ischemia (from 0.62 to 0.68) and myocardial infarction (from 0.64 to 0.71) and 1-year composite ischemia (from 0.61 to 0.65) and myocardial infarction (from 0.63 to 0.69) end points.


CONCLUSIONS
Among ACS patients managed with an early invasive strategy, baseline angiographic markers of disease burden, calcification, lesion severity, lower left ventricular ejection fraction, and morphological characteristics provided important added independent predictive value for 30-day and 1-year ischemic outcomes, beyond the well-recognized clinical risk factors. These findings emphasize the prognostic importance of the diagnostic angiogram in the risk stratification of patients presenting with ACSs.


BACKGROUND
URL: http://clinicaltrials.gov. Unique identifier: NCT00093158.
Lansky
Alexandra J
AJ
Columbia University Medical Center, New York, NY 10022, USA. alexandralansky@gmail.com
Goto
Kenji
K
Cristea
Ecaterina
E
Fahy
Martin
M
Parise
Helen
H
Feit
Frederick
F
Ohman
E Magnus
EM
White
Harvey D
HD
Alexander
Karen P
KP
Bertrand
Michel E
ME
Desmet
Walter
W
Hamon
Martial
M
Mehran
Roxana
R
Moses
Jeffrey
J
Leon
Martin
M
Stone
Gregg W
GW
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology / Q000503:physiopathology / Q000628:therapy*; D000368:Aged; D002114:Calcinosis; D002404:Catheterization; D017023:Coronary Angiography / Q000379:methods*; D001026:Coronary Artery Bypass; D023903:Coronary Restenosis; D018450:Disease Progression; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007511:Ischemia; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012307:Risk Factors; D013318:Stroke Volume; D016019:Survival Analysis