A routine invasive strategy may significantly reduce death risk in unstable angina

1. Routine invasive coronary angiography was associated with a reduction in 12-month mortality in patients with unstable angina.

2. The survival benefit of invasive coronary angiography management persisted when angiography was delayed up to 2 months after the first episode of unstable angina.

Evidence Rating Level: 2 (Good)

Study Rundown: Acute coronary syndrome consists of ST segment elevation myocardial infarction (STEMI), and non-ST segment elevation conditions, mainly unstable angina (UA) and non-ST segment elevation MI (non-STEMI). Currently, guidelines recommend routine coronary angiography for non-STEMI patients, but not for patients with UA. Although randomized controlled trials have been conducted with UA patients, there is little evidence regarding the routine use of invasive coronary angiography in UA patients. The authors of this study, therefore, aimed to assess the effect of angiography on mortality in UA, while incorporating the results of additional cardiac procedures and events. In general, it was observed that patients with UA benefitted from invasive coronary angiography during their hospitalization and up to 2 months after discharge. This study has several limitations. First, allocation of angiography was nonrandom since the study was observational in nature. Additionally, there may have been unmeasured confounders that influenced data, such as a lack of information about patient rehabilitation and noninvasive tests. Overall, this study suggests that incorporating a routine invasive strategy may significantly improve UA patient prognosis.

Click to read the study, published in the Annals of Internal Medicine

Relevant Reading: Diagnosis and Management of Acute Coronary Syndrome: An Evidence-Based Update

In-Depth [retrospective cohort]: The authors conducted a retrospective observational study, sampling patients from 1 July 2001 to 30 June 2011 with a discharge diagnosis of unstable angina. In total, 33 901 patients were included in the study. When comparing patients who received angiography at the index admission, versus those with more conservative management, the authors did not observe differences in the relative effect of angiography with respect to age, sex, or comorbid conditions. Significantly, a 52% decrease in 12-month mortality was seen with routine angiography (hazard ratio 0.48, 95%CI 0.38 to 0.61). Revascularization did not confer additional mortality benefit compared to angiography alone. Finally, the predicted cumulative probability of death at 12 months was 0.024 (95%CI 0.021 to 0.027) for patients who received angiography within 2 months of their first case of UA, compared to 0.091 (95%CI 0.090 to 0.105) for patients with conservative management.

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