Early versus delayed invasive intervention in acute coronary syndromes
Open accessAbstract
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.)
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Multiple studies have indicated that an early invasive strategy is beneficial in high-risk sub-groups.
“Multiple studies have indicated that an early invasive strategy is beneficial in high-risk sub-groups.”
From 2023 ESC guidelines for the management of cardiovascular disease in patients with diabetes. (2023) · cites this paper as [441]
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- Authors
- Mehta, S. R., Granger, C. B., Boden, W. E., Steg, P. G., Bassand, J.-P., Faxon, D. P., Afzal, R., Chrolavicius, S., Jolly, S. S., Widimsky, P., Avezum, A., Rupprecht, H.-J., Zhu, J., Col, J., Natarajan, M. K., Horsman, C., Fox, K. A. A., & Yusuf, S.
- Affiliations
- Population Health Research Institute (CA)
- Duke Clinical Research Institute (US)
- University at Buffalo, State University of New York (US)
- Centre Hospitalier Universitaire de Besançon (FR)
- Brigham and Women's Hospital (US)
- Fu Wai Hospital (CN)
- Edinburgh Royal Infirmary (GB)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2009-05-21
- Volume
- 360
- Issue
- 21
- Pages
- 2165-2175
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- OpenAlex
- W2132393613
- Cited by
- 925
- References
- 31
- Citations by year
- 2026: 24 · 2025: 48 · 2024: 39 · 2023: 45 · 2022: 47 · 2021: 55 · 2020: 44 · 2019: 47 · 2018: 54 · 2017: 54 · 2016: 62 · 2015: 61 · 2014: 61 · 2013: 56 · 2012: 69
- FWCI
- 48.72
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- ArTS Archivio della ricerca di Trieste (University of Trieste https://www.units.it/) (submittedVersion)
- Funders
- Bristol-Myers Squibb
- Eli Lilly and Company
- Pfizer
- AstraZeneca
- GlaxoSmithKline
- Sanofi
- Heart and Stroke Foundation of Canada
- Boston Scientific Corporation
- Astellas Pharma
- Servier
- Abbott Vascular
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Acute Myocardial Infarction Research
- Health Sciences › Medicine › Surgery › Coronary Interventions and Diagnostics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Antiplatelet Therapy and Cardiovascular Diseases
- Keywords
- acute coronary syndrome, non-ST-segment elevation, early invasive strategy, coronary angiography timing, myocardial infarction, refractory ischemia, mortality, high-risk patients, risk stratification, stroke, coronary revascularization, percutaneous coronary intervention
- MeSH terms
- Aged, Angina Pectoris, Coronary Artery Bypass, Female, Humans, Male, Middle Aged, Myocardial Infarction, Risk, Time Factors, Angioplasty, Balloon, Coronary, Coronary Angiography, Outcome Assessment, Health Care, Stroke, Kaplan-Meier Estimate, Acute Coronary Syndrome
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