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Original Research |

Effectiveness of an Early Versus a Conservative Invasive Treatment Strategy in Acute Coronary Syndromes: A Nationwide Cohort StudyEffectiveness of Early Invasive Treatment Strategies in ACS

Kim Wadt Hansen, MD; Rikke Sorensen, MD; Mette Madsen, MSc; Jan Kyst Madsen, DMSc; Jan Skov Jensen, DMSc; Lene Mia von Kappelgaard, MScPH; Poul Erik Mortensen, MD; Theis Lange, MSc; and Soren Galatius, DMSc
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 27 October 2015.


From University Hospital Bispebjerg, University of Copenhagen, and University of Southern Denmark, Copenhagen; University Hospital Gentofte, Hellerup; University Hospital Holbæk, Holbæk; and Odense University Hospital, Odense, Denmark.

Note: Dr. Hansen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acknowledgment: The authors thank the physicians providing data to the Danish Heart Registry for their hard work and continuous efforts.

Financial Support: By the Department of Cardiology at University Hospital Gentofte and grants from Abbott Vascular Research and the Master Mason Lauritz Peter Christensen and wife Kirsten Sigrid Christensen Foundation.

Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-0303.

Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer.

Reproducible Research Statement:Study protocol and data set: Not available. Statistical code: Available from Dr. Hansen (e-mail, kim.wadt.hansen@regionh.dk).

Requests for Single Reprints: Kim Wadt Hansen, MD, Department of Cardiology, Bispebjerg University Hospital, Building 67, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.

Current Author Addresses: Drs. Hansen and Galatius: Department of Cardiology, Bispebjerg University Hospital, Building 67, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.

Drs. Sorensen and Jensen: Department of Cardiology, Gentofte University Hospital, Kildegårdsvej 28, 2900 Hellerup, Denmark.

Ms. M. Madsen: Department of Public Health, University of Copenhagen, øster Farimagsgade 5, PO Box 2099, 1014 Copenhagen, Denmark.

Dr. J.K. Madsen: Emergency Department, Holbæk University Hospital, Smedelundsgade 60, 4300 Holbæk, Denmark.

Ms. von Kappelgaard: National Institute of Public Health, University of Southern Denmark, øster Farimagsgade 5, 1353 Copenhagen, Denmark.

Dr. Mortensen: Department of Thoracic Surgery, Odense University Hospital, Søndre Boulevard 29, 5000 Odense, Denmark.

Mr. Lange: Section of Biostatistics, Department of Public Health, University of Copenhagen, øster Farimagsgade 5, PO Box 2099, 1014 Copenhagen, Denmark.

Author Contributions: Conception and design: K.W. Hansen, M. Madsen, J.K. Madsen, T. Lange, S. Galatius.

Analysis and interpretation of the data: K.W. Hansen, P.E. Mortensen, T. Lange, S. Galatius.

Drafting of the article: K.W. Hansen, T. Lange.

Critical revision of the article for important intellectual content: K.W. Hansen, R. Sorensen, M. Madsen, J.K. Madsen, J.S. Jensen, P.E. Mortensen, T. Lange, S. Galatius.

Final approval of the article: K.W. Hansen, R. Sorensen, M. Madsen, J.K. Madsen, J.S. Jensen, L.M. von Kappelgaard, P.E. Mortensen, T. Lange, S. Galatius.

Statistical expertise: K.W. Hansen, M. Madsen, T. Lange.

Obtaining of funding: K.W. Hansen, J.S. Jensen, S. Galatius.

Administrative, technical, or logistic support: J.S. Jensen, S. Galatius.

Collection and assembly of data: K.W. Hansen, P.E. Mortensen.


Ann Intern Med. 2015;163(10):737-746. doi:10.7326/M15-0303
Text Size: A A A

Background: Randomized clinical trials have found that early invasive strategies reduce mortality, myocardial infarction (MI), and rehospitalization compared with a conservative invasive approach in acute coronary syndromes (ACSs), but the effectiveness of such strategies in real-world settings is unknown.

Objective: To investigate adverse cardiovascular outcomes of an early versus a conservative invasive strategy in a national cohort of patients with ACSs.

Design: Retrospective cohort study.

Setting: Administrative health care data on hospitalizations, procedures, and outcomes abstracted from the Danish national registries and covering all acute invasive procedures in patients presenting with an ACS.

Patients: 19 704 propensity score–matched patients hospitalized with a first ACS between 1 January 2005 and 31 December 2011.

Measurements: Risk for cardiac death or rehospitalization for MI within 60 days of hospitalization.

Results: Compared with a conservative approach, early invasive strategies were associated with a lower risk for cardiac death (cumulative incidence, 5.9% vs. 7.6%; adjusted hazard ratio [HR], 0.75 [95% CI, 0.66 to 0.84]; P < 0.001). Similar results were found for rehospitalization for MI (cumulative incidence, 3.4% vs. 5.0%; adjusted odds ratio, 0.67 [CI, 0.58 to 0.77]; P < 0.001) and all-cause death (cumulative incidence, 7.3% vs. 10.6%; adjusted HR, 0.65 [CI, 0.59 to 0.72]; P < 0.001).

Limitation: Potential residual confounding due to lack of core clinical variables.

Conclusion: In this real-world cohort of patients with a first hospitalization for an ACS, the use of an early invasive treatment strategy was associated with a lower risk for cardiac death and rehospitalization for MI compared with a conservative invasive approach.

Primary Funding Source: Department of Cardiology, University Hospital Gentofte.

Figures

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Appendix Figure 1.

Study flow diagram.

ACS = acute coronary syndrome.

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Figure 1.

Cumulative incidence curves for cardiac death and rehospitalization for MI within 60 d of index hospitalization.

The HR and OR reflect outcomes at 60 d. CIS = conservative invasive strategy; EIS = early invasive strategy; HR = hazard ratio; MI = myocardial infarction; OR = odds ratio.

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Appendix Figure 2.

Cumulative incidence curves for all-cause death within 60 d of index hospitalization.

The HR reflects the outcome at 60 d. CIS = conservative invasive strategy; EIS = early invasive strategy; HR = hazard ratio.

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Figure 2.

Associations between early versus conservative invasive strategies and cardiac death, by selected patient characteristics.

Reported P values for additive interaction were adjusted for multiple comparisons by using the Holm–Bonferroni method. ACS = acute coronary syndrome; CABG = coronary artery bypass grafting; CIS = conservative invasive strategy; EIS = early invasive strategy; PCI = percutaneous coronary intervention.

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Appendix Figure 3.

Distribution of propensity scores in the unmatched and propensity score–matched cohorts, by treatment group.

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Appendix Figure 4.

Comparison of cumulative incidence curves estimated by the Kaplan–Meier method and the nonparametric Nelson–Aalen method, by treatment group.

1 − KM = cumulative incidence (1 minus the estimated survival probability) as estimated by the Kaplan–Meier method; CIF = cumulative incidence function.

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