Patterns of Early Coronary Angiography Use for NSTEMI

Study Questions:

What are the patient- and hospital-level variations in early angiography use among non–ST-segment elevation myocardial infarction (NSTEMI) patients?


The investigators analyzed NSTEMI patients included in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012-2014) who underwent in-hospital angiography. The target population for this study included patients presenting directly to percutaneous coronary intervention (PCI)-capable hospitals who received invasive coronary angiography, and included 245,966 patients. Timing of angiography was categorized as early (≤24 hours) versus delayed (>24 hours). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures. To investigate factors associated with early angiography ≤24 hours, the authors used a logistic generalized estimating equation regression with an exchangeable working correlation matrix to account for within-hospital clustering of outcome to model the probability of early versus delayed angiography.


A total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7-100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores.


The authors concluded that in contemporary US practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients, and hospital-level use of early angiography varied widely despite few differences in case mix.


This study reports that among NSTEMI patients undergoing in-hospital angiography in contemporary US practice, only 58% underwent early angiography (≤24 hours) and that high-risk clinical characteristics recommended by practice guidelines for triage to early angiography were in fact associated with lower use of early angiography. Furthermore, there was wide variation in the hospital-level use of early angiography despite few differences in case mix across hospitals. These results suggest that time-sensitive treatment algorithms similar to those used to accomplish reperfusion with primary PCI for STEMI may help increase the use of timely angiography within 24 hours of hospital presentation for appropriate high-risk NSTEMI patients. It should also be noted that not all NSTEMI patients need or benefit from early angiography within 24 hours.

Clinical Topics: Acute Coronary Syndromes, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Acute Heart Failure, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, ACTION Registry, Coronary Angiography, Creatinine, Heart Failure, Myocardial Infarction, Percutaneous Coronary Intervention, Quality of Health Care, Triage, Troponin

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