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Prevalence, Predictors, and Impact of Conservative Medical Management for Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Who Have Angiographically Documented Significant Coronary Disease

Mark Y. Chan, MD, MHS^_*, Kenneth W. Mahaffey, MD, FACC^_*, Lena J. Sun, MS^_*, Karen S. Pieper, MS^_*, Harvey D. White, MD, FACC, Philip E. Aylward, MD, FACC, James J. Ferguson, MD, FACC, Robert M. Califf, MD, FACC^_*, Matthew T. Roe, MD, MHS, FACC^_*,_*

^_* Duke Clinical Research Institute, Durham, North Carolina
Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand
Flinders Medical Center, Adelaide, Australia
Texas Heart Institute, St. Luke's-Episcopal Hospital, Houston, Texas.

^_* Reprint requests and correspondence: Dr. Matthew T. Roe, 2400 Pratt Street, Terrace Level, Room 0311, Durham, North Carolina 27705. (Email: matthew.roe{at}duke.edu).

Objectives: We sought to characterize the utilization and impact of a conservative medical management strategy for patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) and significant coronary artery disease on early angiography.

Background: Practice guidelines recommend an early invasive management strategy for NSTE ACS, but revascularization procedures may not always be performed after early angiography, even when significant coronary artery disease is present.

Methods: We evaluated 8,225 intermediate- to high-risk NSTE ACS patients with at least 1 coronary lesion >50% stenosis on early angiography from the SYNERGY (Superior Yield of the New Strategy of Enoxaparin, Revascularization, and Glycoprotein IIb/IIIa Inhibitors) trial (2001 to 2003), comparing patients treated with conservative medical management with those who underwent in-hospital percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) within 7 days of randomization.

Results: A total of 2,633 patients (32%) were medically managed, 4,294 (52%) underwent PCI, and 1,298 (16%) underwent CABG. The strongest independent predictors of conservative medical management versus any intervention were prior CABG, lower body weight, lack of a reinfarction between randomization and catheterization, and 3-vessel disease. With conservative medical management, the cumulative risk of 1-year mortality after discharge increased rapidly during the first 90 days and thereafter remained higher at 7.7% compared with that seen in patients treated with PCI (3.6%) or CABG (6.2%).

Conclusions: One-third of patients with NSTE ACS and significant coronary disease on early angiography were managed without in-hospital revascularization in the SYNERGY trial, and these patients had an increased risk of late mortality. These findings highlight the need for novel treatment approaches for NSTE ACS patients who are not candidates for revascularization. (SYNERGY trial; NCT00043784)

Key Words: conservative medical management • coronary artery disease • non-ST-segment elevation acute coronary syndrome • prognosis

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   CAD = coronary artery disease   DES = drug-eluting stent(s)   GRACE = Global Registry of Acute Coronary Events score   MI = myocardial infarction   NSTE ACS = non–ST-segment elevation acute coronary syndromes   PCI = percutaneous coronary intervention