Importance of Risk Assessment in Timing of Invasive Coronary Evaluation and Treatment of Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome: Insights From the VERDICT Trial

• Published in: Journal of the American Heart Association Vol. 10; no. 19; p. e022333
• Main Authors: Butt, Jawad H, Kofoed, Klaus F, Kelbæk, Henning, Hansen, Peter R, Torp-Pedersen, Christian, Høfsten, Dan, Holmvang, Lene, Pedersen, Frants, Bang, Lia E, Sigvardsen, Per E, Clemmensen, Peter, Linde, Jesper J, Heitmann, Merete, Hove, Jens Dahlgaard, Abdulla, Jawdat, Gislason, Gunnar, Engstrøm, Thomas, Køber, Lars
• Format: Journal Article
• Language: English
• Published: England John Wiley and Sons Inc 05.10.2021; Wiley
• Subjects: acute coronary syndrome; Acute Coronary Syndrome - diagnostic imaging; Acute Coronary Syndrome - therapy; Coronary Angiography; GRACE score; heart failure; Humans; invasive coronary angiography; mortality; Original Research; Risk Assessment; Time Factors; Treatment Outcome; invasive coronary angiography; mortality; heart failure; acute coronary syndrome; GRACE score
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.121.022333

Background The optimal timing of invasive examination and treatment of high-risk patients with non-ST-segment-elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard-care invasive coronary angiography on the risk of all-cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. Methods and Results Patients with clinical suspicion of non-ST-segment-elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48-72 hours) invasive strategy. The primary outcome of the present study was all-cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow-up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16-3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63-1.10]) ( =0.006). Conclusions In patients with non-ST-segment-elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high-risk and low-risk patients with non-ST-segment-elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02061891.