title: Hospital patterns of medical management strategy use for patients with non-ST-elevation myocardial infarction and 3-vessel or left main coronary artery disease.
abstract: BACKGROUND
  Patients with non-ST-elevation myocardial infarction (NSTEMI) and three-vessel or left main coronary disease (3VD/LMD) have a high risk of long-term mortality when treated with a medical management strategy (MMS) compared with revascularization.
  
  
  METHODS
  We evaluated patterns of use and patient features across United States hospitals designated by MMS for NSTEMI patients with 3VD/LMD included in the ACTION Registry-GWTG from 2007-2012.
  
  
  RESULTS
  A total of 42,535 patients without prior bypass surgery were found to have 3VD (≥50% stenosis in all major coronary vessels) or LMD (≥50% lesion) during in-hospital angiography at 423 hospitals with percutaneous and surgical revascularization capabilities. Hospitals (n = 316) with an adequate volume (≥25 NSTEMI patients treated) were stratified into tertiles defined by use of MMS; differences in patient characteristics and outcomes were analyzed. The proportion of NSTEMI patients treated with MMS at all hospitals varied from 16% to 19% each quarter and did not change significantly from 2007 to 2012 (P trend = .11). Among hospitals with adequate volume, the proportion of patients treated with MMS also varied widely (median 17.1%, range: 0.0-44.8%, P < .0001). Patient baseline characteristics, predicted mortality risk, actual in-hospital mortality rates, and discharge treatments were similar across hospital tertiles.
  
  
  CONCLUSIONS
  Close to 20% of patients with NSTEMI and 3VD/LMD identified during in-hospital angiography are treated with MMS without revascularization in contemporary practice. Since the use of MMS varies widely across hospitals despite a relatively similar hospital-level case mix, these findings suggest that there is no standard threshold for the use of revascularization in NSTEMI patients with 3VD/LMD.
authors.affiliation: Duke Clinical Research Institute, Durham, NC; Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Ralf E
authors.initials: RE
authors.lastname: Harskamp
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Tracy Y
authors.initials: TY
authors.lastname: Wang
authors.affiliation: Veterans Affairs Boston Healthcare System, Boston, MA; TIMI Study Group, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.affiliation: TIMI Study Group, Boston, MA; Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Wiviott
authors.affiliation: University of California Davis Medical Center, Sacramento, CA.
authors.forename: Ezra A
authors.initials: EA
authors.lastname: Amsterdam
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Shuang
authors.initials: S
authors.lastname: Li
authors.affiliation: Duke Clinical Research Institute, Durham, NC.
authors.forename: Laine
authors.initials: L
authors.lastname: Thomas
authors.affiliation: Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Robbert J
authors.initials: RJ
authors.lastname: de Winter
authors.affiliation: Duke Clinical Research Institute, Durham, NC. Electronic address: matthew.roe@duke.edu.
authors.forename: Matthew T
authors.initials: MT
authors.lastname: Roe
mesh_terms: D000367:Age Factors; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000628:therapy*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data*; D062645:Percutaneous Coronary Intervention / Q000706:statistics & numerical data; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012042:Registries; D014481:United States / Q000453:epidemiology