Physicians' Academy for Cardiovascular Education

Conservative management ACS associated with lower recommended therapy use and more events

Literature - De Luca L et al., Eur Heart J Cardiovasc Pharmacother 2015

Contemporary antithrombotic strategies in patients with acute coronary syndromes managed without revascularization: insights from the EYESHOT study


De Luca L, Leonardi S, Smecca IM, et al.
Eur Heart J Cardiovasc Pharmacother 2015 DOI: http://dx.doi.org/10.1093/ehjcvp/pvv006
 

Background

Patients with acute coronary syndromes (ACS) who do not receive coronary revascularisation but are medically managed, fall into two distinct categories: patients who are not submitted to coronary angiography (CA) and those who are not revascularised after CA. The first group appears to be at risk of progressively higher risk of mortality over the years, while the latter shows a stably lower mortality rate [1-4].
This study used data from the EYESHOT (EmploYEd antithrombotic therapies in patients with acute coronary Syndromes HOspitalized in iTalian cardiac care units) registry to examine patterns of antithrombotic therapies prescribed during the index hospitalisation among medically managed patients with ACS. EYESHOT was a multicentre, observational, prospective, nation-wide study evaluating in-hospital use of antithrombotic therapies in consecutive ACS patients admitted to intensive cardiac care units (CCU) during two 3-week periods [5]. 2585 patients were enrolled. Of 1519 patients with an initial non STE-elevation (NSTE)-ACS diagnosis, 649 (42.7%) were managed medically, of whom 388 (59.8%) underwent CA. Among 1066 STEMI patients, 134 (12.6%) were managed medically, of whom 90 (67.2%) underwent CA.
 

Main results

  • Medically managed patients not receiving CA more often received low-molecular-weight heparins (LMWHs, 58.4% vs. 42.1%, P<0.0001) and clopidogrel (64.9% vs. 55.2%, P=0.007). Unfractioned heparin (UFH) was less often used in ‘no CA’ patients than in the ‘after CA’  group (10.2% vs. 58.4%, P=0.007), as were aspirin (87.2% vs. 93.1%, P=0.006), ticagrelor (10.8 vs. 26.2%, P<0.0001) and prasugrel (1.0 vs. 3.6%, P=0.03).
  • 3.2% patients in the ‘no CA’ group switched P2Y12 inhibitor, as compared with 7.3% in the ‘after CA’ group. Overall, an upgrade from clopidogrel to a novel P2Y12 inhibitor occurred in 2.0% and a downgrade to clopidogrel or ticlopidine in 3.2%. Switching to another novel P2Y12 inhibitor was seen in 0.3%.
  • At discharge, 58.8% of patients with a final diagnosis of STEMI and NSTE-ACS received DAPT, and 29.2% were prescribed aspirin alone.
    Predictors of non-prescription of DAPT at discharge were indication to CABG (23.2% of patients undergoing CA) (OR: 9.87, 95%CI: 5.39-18.08, P<00001), absence of coronary stenosis at angiography (OR: 3.41, 95%CI: 1.96-5.92, P<0.0001), recurrence of bleeding events during hospitalisation (OR: 5.28, 95%CI: 2.43-11.47, P<0.0001) and a history of bleeding (OR: 1.81, 95%CI: 1.09-2.99, P<0.02).
  • During hospitalisation, more stroke/transient ischaemic attacks (1.6% vs. 0.2%, P=0.04) were seen in the ‘no CA’ vs. ‘after CA’ group, as well as higher mortality (7.9% vs. 2.7%, P=0.0009).
    The rate of myocardial (re)infaction (0.7 vs. 0.2%) and major bleeding (3.0 vs. 1.5%) did not significantly differ between the two groups.

Conclusion

This study shows that in a contemporary cohort of consecutive ACS patients, a substantial proportion of patients, mainly those presenting with NSTE-ACS, is conservatively managed. A lower rate of recommended antithrombotic therapy and higher in-hospital outcome rates were seen in those who did not receive CA as compared to those who did.
Among medically managed patients, it is useful to distinguish those who did not even receive CA and patients who are not revascularised after CA, since they have different therapeutic strategies and prognosis. In this real-world registry, those not receiving CA showed a higher rate of risk factors and comorbidities as well as CV events, which appears to be due mainly to differential baseline characteristics.
 
Find this article online at Eur Heart J Cardiovascular Pharmacotherapy
 

References

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2. Kadakia MB, Desai NR, Alexander KP, et al, National Cardiovascular Data Registry. Use of anticoagulant  agents and risk of bleeding among patients admitted with myocardial infarction: a report from the NCDR ACTION Registry—GWTG (National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With the Guidelines). JACC Cardiovasc Interv 2010;3:1166–1177.
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with non-ST-segment elevation acute coronary syndromes treated with invasive versus conservative management strategies: results from the CRUSADE quality improvement initiative. Am Heart J 2009;158:748–754.
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5. De Luca L, Leonardi S, Cavallini C, et al, on behalf of the EYESHOT investigators. Contemporary antithrombotic strategies in patients with acute coronary syndromes admitted to Cardiac Care Units in Italy: the EYESHOT study. Eur Heart J Acute Cardiovasc Care 2014; pii:2048872614560505 [Epub ahead of print].