title: Association Between Clinical Pathways Leading to Medical Management and Prognosis in Patients With NSTEACS.
abstract: OBJECTIVE
  A large proportion of patients with non-ST-segment elevation acute coronary syndrome (NSTEACS) are initially selected for medical management (MM) and do not undergo coronary revascularization during or immediately after the index event. The aim of this study was to explore the clinical pathways leading to MM in NSTEACS patients and their influence on prognosis.
  
  
  METHODS
  Patient characteristics, pathways leading to MM, and 2-year outcomes were recorded in a prospective cohort of 5591 NSTEACS patients enrolled in 555 hospitals in 20 countries across Europe and Latin America. Cox models were used to assess the impact of hospital management on postdischarge mortality.
  
  
  RESULTS
  Medical management was the selected strategy in 2306 (41.2%) patients, of whom 669 (29%) had significant coronary artery disease (CAD), 451 (19.6%) had nonsignificant disease, and 1186 (51.4%) did not undergo coronary angiography. Medically managed patients were older and had higher risk features than revascularized patients. Two-year mortality was higher in medically managed patients than in revascularized patients (11.0% vs 4.4%; P < .001), with higher mortality rates in patients who did not undergo angiography (14.6%) and in those with significant CAD (9.3%). Risk-adjusted mortality was highest for patients who did not undergo angiography (HR = 1.81; 95%CI, 1.23-2.65), or were not revascularized in the presence of significant CAD (HR = 1.90; 95%CI, 1.23-2.95) compared with revascularized patients.
  
  
  CONCLUSIONS
  Medically managed NSTEACS patients represent a heterogeneous population with distinct risk profiles and outcomes. These differences should be considered when designing future studies in this population.
authors.affiliation: Grupo de Investigación Multidisciplinar Traslacional, Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Instituto de Investigación i+12, Hospital Universitario 12 de Octubre, Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain. Electronic address: hector.bueno@cnic.es.
authors.forename: Héctor
authors.initials: H
authors.lastname: Bueno
authors.affiliation: Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Stuart
authors.initials: S
authors.lastname: Pocock
authors.affiliation: Departamento Médico Global, Evidencia Médica e Investigación Observacional, AstraZeneca, Madrid, Spain.
authors.forename: Jesús
authors.initials: J
authors.lastname: Medina
authors.affiliation: Department of Cardiology, Hôpital Européen Georges Pompidou & René Descartes University, Paris, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Danchin
authors.affiliation: Department of Public Health, Universiteit Gent, Vakgroep Maatschappelijke Gezondheidkunde, Gent, Belgium.
authors.forename: Lieven
authors.initials: L
authors.lastname: Annemans
authors.affiliation: Département Médical, AstraZeneca France, Rueil-Malmaison, France.
authors.forename: Muriel
authors.initials: M
authors.lastname: Licour
authors.affiliation: Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: John
authors.initials: J
authors.lastname: Gregson
authors.affiliation: Departamento Médico Global, Evidencia Médica e Investigación Observacional, AstraZeneca, Madrid, Spain.
authors.forename: Ana María
authors.initials: AM
authors.lastname: Vega
authors.affiliation: Departement Cardiovasculaire Wetenschappen, Universiteit van Leuven, Leuven, Belgium.
authors.forename: Frans
authors.initials: F
authors.lastname: van de Werf
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging / Q000188:drug therapy*; D000367:Age Factors; D000368:Aged; D000789:Angina, Unstable / Q000000981:diagnostic imaging / Q000188:drug therapy*; D015331:Cohort Studies; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000188:drug therapy*; D019091:Critical Pathways; D005060:Europe; D005260:Female; D006801:Humans; D007843:Latin America; D008297:Male; D009026:Mortality; D009204:Myocardial Revascularization; D000072658:Non-ST Elevated Myocardial Infarction / Q000000981:diagnostic imaging / Q000188:drug therapy*; D016017:Odds Ratio; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D016896:Treatment Outcome
keywords: Acute coronary syndrome; Coronariografía; Coronary angiography; Coronary revascularization; Medical management; Prognosis; Pronóstico; Revascularización coronaria; Síndrome coronario agudo; Tratamiento médico