Sara Vogrin, MBBS, MBiostat; Richard Harper, MBBS; Elizabeth Paratz, MBBS; Andrew MacIsaac, MBBS; Jodie Burchell, PhD; Belinda Smith, MBBS; Anthony Scott, PhD; Jongsay Yong, PhD; Vijaya Sundararajan, MD, MPH
Grant Support: By National Health and Medical Research Council of Australia Partnership Grant 567217 and Bupa Health Foundation Grant 97.
Disclosures: Drs. Vogrin and Sundararajan report grants from the National Health and Medical Research Council, Victorian Department of Health and Human Services, and Bupa Health Foundation during the conduct of the study. Dr. Scott reports grants from the National Health and Medical Research Council during the conduct of the study. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-2420.
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 and Johnson & Johnson.
Reproducible Research Statement:Study protocol: Fully described in the article. Statistical code: Available from Dr. Vogrin (e-mail, firstname.lastname@example.org). Data set: Available to qualified researchers by application to the Victorian Department of Health and Human Services; it cannot be released by the investigators.
Requests for Single Reprints: Vijaya Sundararajan, MD, MPH, Department of Medicine, St Vincent's Hospital, University of Melbourne, 4th Floor, Clinical Sciences Building, 29 Regent Street, Fitzroy, Victoria 3065, Australia; e-mail, email@example.com.
Current Author Addresses: Drs. Vogrin, Burchell, and Sundararajan: Department of Medicine, St Vincent's Hospital, University of Melbourne, 4th Floor, Clinical Sciences Building, 29 Regent Street, Fitzroy, Victoria 3065, Australia.
Dr. Harper: Monash Heart, Level 2 (street level), Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia.
Drs. Paratz, MacIsaac, and Smith: Cardiology Department, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia.
Drs. Scott and Yong: Melbourne Institute of Applied Economic and Social Research, Level 5, 111 Barry Street, FBE Building, Parkville, Victoria 3010, Australia.
Author Contributions: Conception and design: S. Vogrin, R. Harper, V. Sundararajan.
Analysis and interpretation of the data: S. Vogrin, R. Harper, V. Sundararajan.
Drafting of the article: S. Vogrin, R. Harper, E. Paratz, B. Smith, A. Scott, J. Yong, V. Sundararajan.
Critical revision for important intellectual content: R. Harper, A. MacIsaac, A. Scott, J. Yong, V. Sundararajan.
Final approval of the article: S. Vogrin, R. Harper, E. Paratz, A. MacIsaac, J. Burchell, B. Smith, A. Scott, J. Yong, V. Sundararajan.
Provision of study materials or patients: V. Sundararajan.
Statistical expertise: J. Burchell, A. Scott, J. Yong, V. Sundararajan.
Obtaining of funding: A. Scott, J. Yong, V. Sundararajan.
Administrative, technical, or logistic support: V. Sundararajan.
Collection and assembly of data: S. Vogrin, J. Burchell, V. Sundararajan.
Non–ST-segment elevation acute coronary syndromes include unstable angina and non–ST-segment elevation myocardial infarction. Most randomized controlled trials of routine versus selective invasive coronary angiography have high rates of crossover from control to intervention groups and do not include subgroup analysis for unstable angina. Consequently, no clear, specific recommendations exist regarding the use of angiography in unstable angina.
To assess the effect of angiography on mortality in unstable angina, incorporating the results of additional cardiac procedures and events.
Longitudinal study using hospital discharge data, discrete-time survival analysis with propensity score adjustment, and sensitivity analysis.
Victoria, Australia, 2001 to 2011.
All residents, all ages.
Routine invasive coronary angiography.
12-month all-cause mortality.
Emergently admitted patients with unstable angina (n = 33 901) who did or did not receive angiography during their first hospitalization were balanced on 44 covariates of propensity score. Routine angiography was associated with a 52% decrease in 12-month mortality (hazard ratio, 0.48 [95% CI, 0.38 to 0.61]); revascularization offered no additional statistical mortality benefit compared with diagnostic angiography alone. The predicted cumulative probability of death at 12 months was 0.024 (CI, 0.021 to 0.027) for patients receiving angiography within 2 months of their index unstable angina versus 0.097 (CI, 0.090 to 0.105) for those not receiving it. Sensitivity analysis demonstrated that to negate the observed effect size, an unmeasured confounder must independently decrease mortality by 90% and have a prevalence gap of 15% or greater between the angiographic groups.
Nonrandom allocation of angiography.
Patients with unstable angina benefit from an invasive management pathway initiated by invasive coronary angiography during their hospitalization and up to 2 months after discharge.
National Health and Medical Research Council, Australia and BUPA Health Foundation.
Vogrin S, Harper R, Paratz E, MacIsaac A, Burchell J, Smith B, et al. Comparative Effectiveness of Routine Invasive Coronary Angiography for Managing Unstable Angina. Ann Intern Med. 2017;166:783–791. doi: 10.7326/M16-2420
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Published: Ann Intern Med. 2017;166(11):783-791.
Published at www.annals.org on 2 May 2017
Acute Coronary Syndromes, Cardiac Diagnosis and Imaging, Cardiology, Coronary Heart Disease, Emergency Medicine.
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