A Milosevic

CW Hamm

DG Katritsis

E Boersma

EA Badings

EF Oosterwerff

EP Navarese

JA Goldstein

K Thygesen

M Ishak

P Damman

PK Cheruvu

RA Kerensky

RK Riezebos

SR Mehta

PubMed

F. Arslan

M. Voskuil

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The management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: early invasive strategy for all?

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Netherlands Heart Journal

Arslan, F

Voskuil, M

Utrecht University Repository

The management of acute coronary syndromes in patients presenting without persistent ST-segment elevation : early invasive strategy for all?

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EDITORIAL C OMMENT
DOI 10.1007/s12471-016-0944-1
Neth Heart J (2017) 25:170–172
The management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation: early invasive
strategy for all?
F. Arslan1,2 · M. Voskuil1
Published online: 5 January 2017
© The Author(s) 2017. This article is available at SpringerLink with Open Access.
It is unquestionable that early invasive reperfusion ther-
apy in the setting of ST-segment elevation myocardial in-
farction (STEMI) has significantly reduced infarct-related
mortality and morbidity [1]. Scientific and social dissemi-
nation campaigns have created a certain awareness both in
the public domain and among physicians with slogans such
as ‘the sooner the better’ and ‘time is muscle’, when faced
with such acute situations. The early diagnosis of ischaemia
plays an equally important role in improving outcome after
myocardial infarction (MI). Cardiac troponins (cTn) play
a central role in detecting myocardial damage and are re-
garded as a cornerstone in the diagnosis of an acute coro-
nary event resulting from atherosclerotic plaque instabil-
ity [2]. On intracoronary imaging studies and post-mortem
observation, acute coronary syndrome without persistent
ST-segment elevation (i. e. non-STEMI, NSTEMI-ACS) is
often seen to be related to ‘milder’ forms of plaque instabil-
ity such as erosion and ulceration-based instability [3–5].
The high-sensitive cTn assays have put the definition of MI
into a new perspective [2]. Early detection is preferable in
any type of injury or disease, but the question of whether
earlier intervention will also result in favourable outcome
at an acceptable cost remains.
In this issue of the Netherlands Heart Journal, Damman
and colleagues give the Dutch ACS Working Group per-
spective on the 2015 ESC Guidelines for the management
of acute coronary syndromes in patients presenting with
 F. Arslan
f.arslan@umcutrecht.nl
1 Laboratory of Experimental Cardiology, University Medical
Center Utrecht, Utrecht, The Netherlands
2 Department of Cardiology, University Medical Center
Utrecht, Utrecht, The Netherlands
NSTEMI.[6] It is a concise analysis which compares the
most relevant changes with the 2011 guidelines for general
cardiology practice. In this editorial, we would like to fur-
ther elaborate on the same-day transfer policy in high-risk
patients.
The current NSTEMI-ACS guidelines put more empha-
sis on the immediate transfer and invasive management on
the same day and/or within 24 h of high-risk patients than
the 2011 version [7]. Fig. 6 and Table 13 in the guidelines
illustrate the timing and treatment strategy in accordance
with a certain risk stratification. If a very-high-risk crite-
rion is met, urgent invasive management is required. This,
of course, is not under debate. However, if one out of the
three high-risk criteria is met, same-day transfer is rec-
ommended as a Class I indication with level of evidence
A (Section 5.6.9 of the guidelines). Unfortunately, the un-
derlying evidence for such an indication and strategy is
lacking, even in the literature that is used by the ESC com-
mittee to substantiate the recommendation.
The studies referred to in the 2015 guidelines are
the TIMACS trial and two meta-analyses [8–10]. In the
TIMACS trial, 3031 NSTEMI-ACS patients were ran-
domly assigned to undergo either early (<24 h) or delayed
(>36 h) coronary angiography after randomisation. There
was no difference between early and delayed interven-
tions in the primary outcome (composite of death, MI or
stroke at 6 months). Patients undergoing early interven-
tion experienced less refractory ischaemia at the cost of
more repeat revascularisations 30 days after randomisation.
A very interesting finding was seen in a prespecified sub-
group analysis. It was only in patients with a GRACE risk
score >140, and not biomarker rise-and-fall and dynamic
ST-T segments as outlined in the ESC 2015 guidelines,
that a significant reduction in the primary outcome was
shown. The lack of benefit of early interventional strategies
Neth Heart J (2017) 25:170–172 171
in preventing death and MI was also a conclusion of the
meta-analyses referred to by the 2015 guidelines [8, 9].
More recent studies fail to show any hard clinical ben-
efit or a benefit in survival in the early over delayed in-
vasive strategy. The RIDDLE-NSTEMI study is a small
randomised trial with 323 patients randomised to either im-
mediate (<2 h) or delayed (2–72 h) intervention. Thirty days
after the index event, 0 vs. 10 new MIs (pre-catheterisation)
were observed in early vs. delayed strategy, respectively.
However, there were more patients with a GRACE risk
score >140 in the delayed group. Furthermore, CABG was
the preferred revascularisation strategy in 24% of the de-
layed intervention patients, while in the early intervention
group only 12% underwent CABG (p = 0.01). This indi-
cates a higher risk profile in the delayed intervention group,
despite randomisation [11].
The OPTIMA trial randomised 142 patients to imme-
diate or deferred (24–48 h) PCI after a diagnostic angiog-
raphy was performed within 3 h of admission. Deferral of
PCI resulted in fewer MIs when compared with immedi-
ate intervention (38% vs. 60%, p = 0.005) at 30 days and
6 months [12]. This difference is rather remarkable given
the fact that more patients in the deferred group had a TIMI
flow of 0–2 (36% vs. 19%, p = 0.02). Five-year follow-up
of the trial did not show any difference between the groups
in the composite of death and spontaneous MI [13].
The ELISA trial randomised 542 patients to either early
(<12 h) or delayed (>48 h) invasive strategy (angiography
and revascularisation if appropriate). The study failed to
show the superiority of early invasive management over
a delayed strategy in terms of death, re-infarction or recur-
rent ischaemia 30 days after NSTEMI-ACS [14].
A recent analysis of 4307 NSTEMI-ACS patients from
the Melbourne Interventional Group registry observed no
mortality hazard in >24 h deferral of PCI during 12-month
follow-up. The main predictors of mortality were older age,
impaired renal function and elevated biomarkers which are
highly relevant in the GRACE risk score.
So far, studies and meta-analysis have not shown that
invasive strategy within 24 h of admission with NSTEMI-
ACS confers any benefit. Detailed analysis of the data
only justifies early invasive management in patients with
a GRACE risk score >140. In the absence of MI-related
complications or refractory angina despite optimal medical
treatment, dynamic ST or T-wave changes or a rise and
fall compatible with MI appears to be an insufficient high-
risk criterion for same-day transfer to a PCI centre. With
the high-sensitive cTn assays in particular, there will be
over-classification of high-risk patients. To corroborate the
statements of Damman and colleagues, we believe that an
early invasive strategy (<24 h) as a Class IA indication is
not supported by the literature, and that it may only be
justified in patients with a GRACE risk score >140. Same-
day transfer of these ‘high-risk’ patients with NSTEMI to
an intervention centre is not likely to result in a clear health
benefit. Future studies have to be awaited to clarify early
invasive strategy [15].
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted
use, distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
made.
References
1. Boersma E. Primary coronary angioplasty vs. thrombolysis G. Does
time matter? A pooled analysis of randomized clinical trials com-
paring primary percutaneous coronary intervention and in-hospi-
tal fibrinolysis in acute myocardial infarction patients. Eur Heart J.
2006;27(7):779–88.
2. Thygesen K, Alpert JS, Jaffe AS, et al. Third universal definition of
myocardial infarction. Eur Heart J. 2012;33(20):2551–67.
3. Kerensky RA, Wade M, Deedwania P, et al. Revisiting the cul-
prit lesion in non-Q-wave myocardial infarction. Results from the
VANQWISH trial angiographic core laboratory. J Am Coll Cardiol.
2002;39(9):1456–63.
4. Cheruvu PK, Finn AV, Gardner C, et al. Frequency and distribution
of thin-cap fibroatheroma and ruptured plaques in human coronary
arteries: a pathologic study. J Am Coll Cardiol. 2007;50(10):940–9.
5. Goldstein JA, Demetriou D, Grines CL, et al. Multiple complex
coronary plaques in patients with acute myocardial infarction.
N Engl J Med. 2000;343(13):915–22.
6. Damman P, van’t Hof AW, ten Berg JM, Jukema JW, Appelman
Y, Liem AH, et al. ESC guidelines for the management of acute
coronary syndromes in patients presenting without persistent ST-
segment elevation: comments from the Dutch ACS working group.
Neth Heart J. 2017;25 doi:10.1007/s12471-016-0939-y.
7. Hamm CW, Bassand JP, Agewall S, et al. ESC Guidelines for the
management of acute coronary syndromes in patients presenting
without persistent ST-segment elevation: The Task Force for the
management of acute coronary syndromes (ACS) in patients pre-
senting without persistent ST-segment elevation of the European
Society of Cardiology (ESC). Eur Heart J. 2011;32(23):2999–3054.
8. Navarese EP, Gurbel PA, Andreotti F, et al. Optimal timing of coro-
nary invasive strategy in non-ST-segment elevation acute coronary
syndromes: a systematic review and meta-analysis. Ann Intern
Med. 2013;158(4):261–70.
9. Katritsis DG, Siontis GC, Kastrati A, et al. Optimal timing of coro-
nary angiography and potential intervention in non-ST-elevation
acute coronary syndromes. Eur Heart J. 2011;32(1):32–40.
10. Mehta SR, Granger CB, Boden WE, et al. Early versus delayed
invasive intervention in acute coronary syndromes. N Engl J Med.
2009;360(21):2165–75.
11. Milosevic A, Vasiljevic-Pokrajcic Z, Milasinovic D, et al. Im-
mediate versus delayed invasive intervention for non-STEMI
patients: the RIDDLE-NSTEMI study. JACC Cardiovasc Interv.
2016;9(6):541–9.
12. Riezebos RK, Ronner E, Ter Bals E, et al. Immediate versus de-
ferred coronary angioplasty in non-ST-segment elevation acute
coronary syndromes. Heart. 2009;95(10):807–12.
13. Oosterwerff EF, Fagel ND, Slagboom T, et al. Impact of per-
cutaneous coronary intervention timing on 5-year outcome in
patients with non-ST-segment elevation acute coronary syn-
172 Neth Heart J (2017) 25:170–172
dromes. The ‘wait a day’ approach might be safer. Neth Heart
J. 2016;24(3):173–80.
14. Badings EA, The SH, Dambrink JH, et al. Early or late intervention
in high-risk non-ST-elevation acute coronary syndromes: results of
the ELISA-3 trial. EuroIntervention. 2013;9(1):54–61.
15. Ishak M, Ali D, Fokkert MJ, et al. Fast assessment and man-
agement of chest pain without ST-elevation in the pre-hospital
gateway: rationale and design. Eur Heart J Acute Cardiovasc Care.
2015;4(2):129–36.


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The management of acute coronary syndromes in patients presenting without persistent ST-segment elevation : early invasive strategy for all?

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