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N Engl J Med. 2009 May 21;360(21):2165-75. doi: 10.1056/NEJMoa0807986.

Early versus delayed invasive intervention in acute coronary syndromes.

Collaborators (257)

Mehta SR, Yusuf S, Avezum A, Bassand JP, Chrolavicius S, Granger CB, Widimsky P, Zhu J, Boden WE, Budaj A, Ceremuzynski L, Col JJ, Diaz R, Faxon DP, Hunt D, Jolly S, Joyner C, Karatzas NB, Kenda M, Lanas F, Moccetti T, Morillo C, Natarajan MK, Paolasso E, Piegas L, Pipilis T, Probstfield J, Rupprecht HJ, Steg PG, Theroux P, Varigos J, Xavier D, Ameriso S, Barsan A, Benedek IS, Bonilla C, Borislav G, Cardona E, Chan YK, Chen WH, Cottin Y, Czepiel A, DeRaedt H, Dorobantu M, Eikelboom J, Finet G, Fodor G, Gardinale E, Gaxiola E, Gregor P, Guimaraes H, Hazarbasanov D, Healey J, Held C, Himbert D, Isaaz K, Iyengar SS, Kalvach P, Kevers L, Klosiewicz-Wasek B, Lang S, Lau CP, Leys D, Maggioni AP, Moulin T, Narendra J, Peeters A, Penika M, Perakis A, Pizzolato G, Qi H, Rassaro A, Renkin J, Rokoss M, Runev N, Stockins B, Sundararajan R, Turazza F, Van Belle E, Wasek W, Yang Y, Zaborski J, Sleight P, Anderson JL, deMets D, Hirsh J, Holmes DR Jr, Johnstone DE, Horsman C, Jedrzejowski B, Meeks B, Afzal R, Pogue J, Boonstra D, Cramp C, Lawrence M, Mead A, Sovereign T, Alico JC, Allende G, Castellanos CR, Fernandez A, Guerrero RA, Licheri AJ, Luciardi HL, Marquez LL, Patocchi C, Zapata G, Jayasinghe R, Lee K, Waites JH, Al Shwafi K, Coussement P, El Allaf D, Janssens L, Vrolix M, Abrantes JA, Alburquerque DC, Carvalho AC, Castro LR, Coutinho M, Greque GV, Leaes PE, Lichter A, Maia LN, Manenti ER, Marin-Neto JA, Mora RD, Nicolau JC, Rabelo A Jr, Ramos RF, Reis G, Rodrigues A, Rossi PR, Bhargava R, Bozek B, Brons S, Cockhill C, Constance C, Diodati J, Esporlas-Jewer I, Gladstone PJ, Gosselin G, Joyal D, Kim HH, Lam A, Madan M, Pallie S, Pilon C, Salehian O, Stimac J, Tanguay JF, Teo K, Traboulsi M, Zimmermann RH, Zaniol D, Castro P, Che J, Chen M, Cheng K, Ding F, Fang W, Gao W, Ge J, Han Y, Jin X, Li S, Li Y, Li Z, Lu S, Qi G, Qiao S, Wang H, Wang L, Wang L, Wang S, Wang W, Wang X, Wang Y, Wang Z, Wen S, Wu Q, Xu B, Xu G, Xu L, Xu Y, Yang T, Yu B, Yu D, Zhang J, Zhang R, Zhang S, Zhang XY, Zhao L, Zhou X, Zhou Y, Hernandez C, Jaramillo NI, Aschermann M, Belohlávek J, Branny M, Groch L, Holm F, Jansky P, Jelínek P, Lisa L, Malik J, Vecera J, Charbonnier B, Ducrocq G, Ferrari E, Fouche R, Grollier G, Kahn JC, Meneveau N, Pacouret G, Py A, Richard A, Schiele F, Blank R, Buerke M, Dominick K, Drexler H, Genth-Zotz S, Giannitsis E, Katus HA, Klauss V, Klutmann M, vom Dahl J, Fotiadis I, Haridas KK, Kerkar PG, Mahorkar UK, Parikh K, Dalkowski M, Goch JH, Kleinrok A, Krasowski W, Pluta W, Siminiak T, Szetemej R, Waseh W, Benedek TM, Kurray P, Meciar P, Kranjec I, Pieper M, Alexander J, Baber Z, Birnbaum Y, Bolad IA, Chandna H, Lui C, Nelson R, Parikh DK, Philbin E, Sonel AF.

Author information

1
Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada. smehta@mcmaster.ca

Abstract

BACKGROUND:

Earlier trials have shown that a routine invasive strategy improves outcomes in patients with acute coronary syndromes without ST-segment elevation. However, the optimal timing of such intervention remains uncertain.

METHODS:

We randomly assigned 3031 patients with acute coronary syndromes to undergo either routine early intervention (coronary angiography < or = 24 hours after randomization) or delayed intervention (coronary angiography > or = 36 hours after randomization). The primary outcome was a composite of death, myocardial infarction, or stroke at 6 months. A prespecified secondary outcome was death, myocardial infarction, or refractory ischemia at 6 months.

RESULTS:

Coronary angiography was performed in 97.6% of patients in the early-intervention group (median time, 14 hours) and in 95.7% of patients in the delayed-intervention group (median time, 50 hours). At 6 months, the primary outcome occurred in 9.6% of patients in the early-intervention group, as compared with 11.3% in the delayed-intervention group (hazard ratio in the early-intervention group, 0.85; 95% confidence interval [CI], 0.68 to 1.06; P=0.15). There was a relative reduction of 28% in the secondary outcome of death, myocardial infarction, or refractory ischemia in the early-intervention group (9.5%), as compared with the delayed-intervention group (12.9%) (hazard ratio, 0.72; 95% CI, 0.58 to 0.89; P=0.003). Prespecified analyses showed that early intervention improved the primary outcome in the third of patients who were at highest risk (hazard ratio, 0.65; 95% CI, 0.48 to 0.89) but not in the two thirds at low-to-intermediate risk (hazard ratio, 1.12; 95% CI, 0.81 to 1.56; P=0.01 for heterogeneity).

CONCLUSIONS:

Early intervention did not differ greatly from delayed intervention in preventing the primary outcome, but it did reduce the rate of the composite secondary outcome of death, myocardial infarction, or refractory ischemia and was superior to delayed intervention in high-risk patients. (ClinicalTrials.gov number, NCT00552513.)

Comment in

PMID:
19458363
DOI:
10.1056/NEJMoa0807986
[Indexed for MEDLINE]
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