Use of Invasive Strategy in Non–ST-Segment Elevation Myocardial Infarction Is a Major Determinant of Improved Long-Term Survival: FAST-MI (French Registry of Acute Coronary Syndrome)

Study Questions:

What is the impact of an early invasive strategy on the outcome of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI)?

Methods:

The authors assessed the long-term outcome of 1,645 patients who presented with an NSTEMI to one of the 223 French hospitals participating in the FAST-MI trial over a 1-month period in 2005. Early invasive strategy was defined as performance of angiography during the initial hospitalization.

Results:

An invasive strategy was used in 80% of the 1,645 patients who presented with NSTEMI. Patients in the invasive group were younger (ages 67 vs. 80 years), less likely to be women (29% vs. 51%), and had a lower GRACE (Global Registry of Acute Coronary Events) risk score (137 vs. 178) compared with patients who were treated conservatively. Conservative therapy was associated with an increase in in-hospital mortality (13% vs. 2%) and blood transfusions (9.1% vs. 4.6%). Patients treated with invasive therapy had significantly lower 3-year all-cause mortality (17% vs. 60%; adjusted hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.35-0.55) and cardiovascular death (8% vs. 36%; adjusted HR, 0.37; 95% CI, 0.27-0.50). The difference in mortality was observed when the analysis was restricted to patients who survived to hospital discharge or in propensity-matched analysis (62% vs. 43%; HR, 0.54; 95% CI, 0.40-0.74; p < 0.001).

Conclusions:

The authors concluded that an invasive strategy is associated with a lower long-term mortality in patients with NSTEMI.

Perspective:

The benefit of early invasive therapy in patients with NSTEMI has been previously demonstrated in multiple meta-analyses and randomized controlled trials. This study demonstrates a dramatic reduction in mortality with an invasive strategy in patients with NSTEMI, although the magnitude of the benefit belies clinical plausibility. It seems likely that the study fails to completely adjust for confounders that influenced the choice of invasive versus conservative therapy.

Clinical Topics: Acute Coronary Syndromes

Keywords: Registries, Myocardial Infarction, Acute Coronary Syndrome, Hospital Mortality


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