title: Regional patterns of use of a medical management strategy for patients with non-ST-segment elevation acute coronary syndromes: insights from the EARLY ACS Trial.
abstract: BACKGROUND
  Regional differences in the profile and prognosis of non-ST-segment elevation acute coronary syndrome (NSTE ACS) patients treated with medical management after angiography remain uncertain.
  
  
  RESULTS
  Using data from the Early Glycoprotein IIb/IIIa Inhibition in Non-ST-Segment Elevation Acute Coronary Syndromes (EARLY ACS) trial, we examined regional variations in the use of an in-hospital medical management strategy in NSTE ACS patients who had significant coronary artery disease (CAD) identified during angiography, factors associated with the use of a medical management strategy, and 1-year mortality rates. Of 9406 patients, 8387 (89%) underwent angiography and had significant CAD; thereafter, 1766 (21%) were treated solely with a medical management strategy (range: 18% to 23% across 4 major geographic regions). Factors most strongly associated with a medical management strategy were negative baseline troponin values, prior coronary artery bypass grafting, lower baseline hemoglobin values, and greater number of diseased vessels; region was not a significant factor. One-year mortality was higher among patients treated with a medical management strategy compared with those who underwent revascularization (7.8% versus 3.6%; adjusted hazard ratio, 1.46; 95% CI, 1.21-1.76), with no significant interaction by region (interaction probability value=0.42).
  
  
  CONCLUSIONS
  Approximately 20% of NSTE ACS patients with significant CAD in an international trial were treated solely with an in-hospital medical management strategy after early angiography, with no regional differences in factors associated with medical management or the risk of 1-year mortality. These findings have important implications for the conduct of future clinical trials, and highlight global similarities in the profile and prognosis of medically managed NSTE ACS patients.
authors.affiliation: Duke Clinical Research Institute, Durham, NC, USA. matthew.roe@duke.edu
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
authors.forename: Jennifer A
authors.initials: JA
authors.lastname: White
authors.forename: Padma
authors.initials: P
authors.lastname: Kaul
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Tricoci
authors.forename: Yuliya
authors.initials: Y
authors.lastname: Lokhnygina
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
authors.forename: Arnoud W
authors.initials: AW
authors.lastname: van't Hof
authors.forename: Gilles
authors.initials: G
authors.lastname: Montalescot
authors.forename: Stefan K
authors.initials: SK
authors.lastname: James
authors.forename: Jorge
authors.initials: J
authors.lastname: Saucedo
authors.forename: E Magnus
authors.initials: EM
authors.lastname: Ohman
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
authors.forename: Judith S
authors.initials: JS
authors.lastname: Hochman
authors.forename: Paul W
authors.initials: PW
authors.lastname: Armstrong
authors.forename: Robert P
authors.initials: RP
authors.lastname: Giugliano
authors.forename: Robert A
authors.initials: RA
authors.lastname: Harrington
authors.forename: Frans
authors.initials: F
authors.lastname: Van de Werf
authors.forename: Robert M
authors.initials: RM
authors.lastname: Califf
authors.forename: L Kristin
authors.initials: LK
authors.lastname: Newby
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D000368:Aged; D017023:Coronary Angiography; D001026:Coronary Artery Bypass; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use*; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors*
chemical_list: D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex