title: Invasive strategy in non-ST-segment elevation acute coronary syndrome: What should be the benchmark target in the real world patients? Insights from BLITZ-4 Quality Campaign.
abstract: OBJECTIVE
  To define a benchmark target for an invasive strategy (IS) rate appropriate for performance assessment in intermediate-to-high risk non-ST-segment elevation acute coronary syndromes (NSTE-ACS).
  
  
  RESULTS
  During the BLITZ-4 campaign, which aimed at improving the quality of care in 163 Italian coronary care units, 4923/5786 (85.1%) of consecutive patients admitted with NSTE-ACS with troponin elevation and/or dynamic ST-T changes on the electrocardiogram were managed with IS. The reasons driving the choice (RDC) for a conservative strategy (CS) in the remaining 863 patients were prospectively recorded. In 33.8%, CS was mandatory because of patients refusal, known coronary anatomy or death before coronary angiography; in 52.8% it was clinically justified because of active stroke, bleeding, advanced frailty, severe comorbidities, contraindication to antiplatelet therapy or because they were considered to be at low risk; only in 13.4% the reasons, such as renal failure, advanced age or other, were less stringent. As compared to patients undergoing IS, those in the CS were 12years older and had significantly more severe comorbidities. The in-hospital and 6-month all-cause mortality were 9.0% vs 0.9% and 22.0% vs 3.9% in CS and IS groups respectively (p<0.0001 for both).
  
  
  CONCLUSIONS
  As the RDC for CS were clinically correct in vast majority of cases the observed 85% invasive strategy rate may be considered as the desirable benchmark target in patients with NSTE-ACS. For the same reason, it remains questionable if the higher rate of IS could have improved the prognosis in CS patients, despite their highly unfavorable prognosis.
authors.affiliation: UOC Cardiologia, Ospedale Cà Foncello, Treviso, Italy. Electronic address: zolivari@ulss.tv.it.
authors.forename: Zoran
authors.initials: Z
authors.lastname: Olivari
authors.affiliation: SC Cardiologia, Ospedale Maria Vittoria, Turin, Italy.
authors.forename: Alessandra
authors.initials: A
authors.lastname: Chinaglia
authors.affiliation: ANMCO Research Center, Florence, Italy.
authors.forename: Lucio
authors.initials: L
authors.lastname: Gonzini
authors.affiliation: UO Cardiologia, Ospedale San Donato, Arezzo, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Falsini
authors.affiliation: SC Cardiologia, Azienda Ospedaliera G. Brotzu, Cagliari, Italy.
authors.forename: Annarita
authors.initials: A
authors.lastname: Pilleri
authors.affiliation: Clinica Cardiologia Gen. Interventistica, AOU Careggi, Firenze, Italy.
authors.forename: Serafina
authors.initials: S
authors.lastname: Valente
authors.affiliation: SC Cardiologia, Ospedale Gen.le Prov.le C.G. Mazzoni, Ascoli Piceno, Italy.
authors.forename: Gianserafino
authors.initials: G
authors.lastname: Gregori
authors.affiliation: UOC Cardiologia, Ospedale Perrino, Brindisi, Italy.
authors.forename: Raffaele
authors.initials: R
authors.lastname: Rollo
authors.affiliation: Cardiologia, Casa di Cura Villa Verde, Taranto, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: My
authors.affiliation: UOC Cardiologia UTIC Emodinamica, Ospedale Belcolle, Viterbo, Italy.
authors.forename: Pietro
authors.initials: P
authors.lastname: Scrimieri
authors.affiliation: UO Cardiologia-UTIC, AORN Giuseppe Moscati, Avellino, Italy.
authors.forename: Tonino
authors.initials: T
authors.lastname: Lanzillo
authors.affiliation: SC Cardiologia, Ospedale Sant'Andrea, Vercelli, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Corrado
authors.affiliation: UO Cardiologia, Ospedale San Jacopo, Pistoia, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Chiti
authors.affiliation: SC Cardiologia, Ospedale Maria Vittoria, Turin, Italy.
authors.forename: Elisa
authors.initials: E
authors.lastname: Picardi
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000453:epidemiology* / Q000628:therapy*; D000368:Aged; D000369:Aged, 80 and over; D019985:Benchmarking / Q000379:methods / Q000592:standards*; D017023:Coronary Angiography / Q000592:standards; D004562:Electrocardiography / Q000592:standards; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D010343:Patient Admission / Q000592:standards* / Q000639:trends; D011787:Quality of Health Care / Q000592:standards*; D016896:Treatment Outcome
keywords: Invasive strategy; Non-ST-segment elevation acute coronary syndromes; Performance measures