Prognosis of patients with non-ST-segment-elevation myocardial infarction and nonobstructive coronary artery disease: propensity-matched analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial.
BACKGROUND
Troponin elevation is a risk factor for mortality in patients with non-ST-segment-elevation acute coronary syndromes. However, the prognosis of patients with troponin elevation and nonobstructive coronary artery disease (CAD) is unknown. Our objective was therefore to evaluate the impact of nonobstructive CAD in patients with non-ST-segment-elevation acute coronary syndromes and troponin elevation enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) trial.


RESULTS
In the ACUITY trial, 3-vessel quantitative coronary angiography was performed in a formal substudy of 6921 patients presenting with non-ST-segment-elevation acute coronary syndromes. Patients with elevated admission troponin levels were stratified by the presence or absence of obstructive CAD (any lesion with quantitative diameter stenosis >50%). Propensity score matching was performed to adjust for baseline characteristics. Of 2442 patients with elevated troponin, 197 (8.8%) had nonobstructive CAD. Maximum diameter stenosis was 87.4 (73.2, 100.0) versus 22.6 (19.2, 25.7; P<0.0001) in patients with versus without obstructive CAD, respectively. Propensity matching yielded 117 patients with nonobstructive CAD and 331 patients with obstructive CAD, with no significant baseline differences between groups. In the matched cohort, overall 1-year mortality was significantly higher in patients with nonobstructive CAD (5.2% versus 1.6%; hazard ratio [95% confidence interval]=3.44 [1.05, 11.28]; P=0.04), driven by greater noncardiac mortality. Conversely, recurrent myocardial infarction and unplanned revascularization rates were significantly higher in patients with obstructive CAD.


CONCLUSIONS
Patients with non-ST-segment-elevation acute coronary syndromes and elevated troponin levels but without obstructive CAD, while having low rates of subsequent myocardial infarction and unplanned revascularization, are still at considerable risk for 1-year mortality from noncardiac causes.


BACKGROUND
http://www.clinicaltrials.gov. Unique identifier: NCT00093158.
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
David
D
Planer
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
Roxana
R
Mehran
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
E Magnus
EM
Ohman
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
Harvey D
HD
White
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
Jonathan D
JD
Newman
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.).
Ke
K
Xu
From the Hadassah-Hebrew University Medical Center, Jerusalem, Israel (D.P.); Icahn School of Medicine at Mount Sinai, New York, NY (R.M.); Cardiovascular Research Foundation, New York, NY (R.M., K.X., G.W.S.); Duke University Medical Center, Durham, NC (E.M.O.); Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand (H.D.W.); and Columbia University Medical Center, New York, NY (J.D.N., G.W.S.). gs2184@columbia.edu.
Gregg W
GW
Stone
D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D000368:Aged; D015415:Biomarkers / Q000097:blood; D006328:Cardiac Catheterization; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D014218:Triage; D014336:Troponin / Q000097:blood
D015415:Biomarkers; D014336:Troponin
acute coronary syndrome; prognosis; propensity score; troponin