Overall, the meta-analysis identified a reduction in ischemia—but not in hard outcomes—with early treatment.
Early invasive management does not reduce the risk of hard clinical outcomes, such as mortality or MI, in women with non-ST-elevation acute coronary syndromes (NSTE ACS), but it is linked with reduced recurrent ischemia, according to a new meta-analysis.
Among high-risk subgroups, however, earlier guideline-recommended coronary angiography and revascularization was linked to better outcomes as well as less recurrent ischemia.The findings highlight the need for prompt intervention—and perhaps a change in guidelines—for the sickest of women who present with NSTE ACS, say investigators.
The2023 ESC guidelinesfor the management of ACS downgraded the recommendation of an early invasive strategy for high-risk patients with NSTE ACS from a class I to a class IIa due to mixed results. The US guidelines,released last month, also include a class IIa recommendation for intervention within 24 hours for patients at high risk of ischemic events.
“People should really focus when a woman presents and think: ‘Should I refer this patient for angiography?’” senior author Vijay Kunadian, MBBS, MD (Newcastle University, Newcastle-upon-Tyne, England), told TCTMD. “We haven’t found any harm in taking these patients to the lab sooner, so rather than having these patients hanging around on the wards, I think clinicians should apply the latest evidence-based guidelines and try their best to provide interventional strategies.”
These include not just coronary angiography but physiological assessment, intravascular imaging, and when appropriate, PCI, she added.
Additionally, she said clinicians should take a closer look at their prescribing habits for women and make sure they are receiving the medications they need. “It might look very simple, but unfortunately, it’s not happening everywhere,” according to Kunadian.
Despite this study being observational, C. Noel Bairey Merz, MD (Smidt Heart Institute, Los Angeles, CA), who commented on the findings for TCTMD, said the data should help advise future guidelines. Recurrent ischemia is “a quality-of-life issue” and should be heavily weighed even if early intervention is not associated with a reduction in mortality, she said.
The findings werepublished onlinelast week in Circulation: Cardiovascular Interventions with first author Gregory B. Mills, MBBS (Newcastle University, England).
Benefit Only for High-Risk Patients
The meta-analysis included data from 2,257 female patients with NSTE ACS enrolled in six trials comparing early versus delayed coronary angiography. The median time to treatment was 5 hours in the early group (n = 1,141) and 49 hours in the delayed group (n = 1,116).
They found no significant reduction in the risk of the primary endpoint of all-cause mortality or MI at 6 months with early compared with delayed treatment (7.4% vs 9.1%; HR 0.79; 95% CI 0.60-1.06), but earlier intervention was associated with less recurrent ischemia (2.8% vs 4.6%; HR 0.60; 95% CI 0.39-0.94).
The prespecified subgroup analysis identified significant benefits for early treatment with regard to the primary endpoint among high-risk patients with a Global Registry of Acute Coronary Events (GRACE) score above 140 (HR 0.65; 95% CI 0.45-0.94; P for interaction = 0.035) as well as for those with elevated cardiac biomarkers (HR 0.64; 95% CI 0.45-0.91; P for interaction = 0.018).
Women have been vastly underrepresented in the major ACS trials, usually making up around 25% of participants, according to Kunadian. The new findings highlight a valuable strategy in that “to avoid recurrent ischemia, . . . taking them to the lab sooner is a good thing,” she said. Additionally, because women have a greater tendency to bleed, sending them for angiography and unearthing a diagnosis sooner—ruling out MI with nonobstructive coronary arteries, say—could enable them to discontinue antiplatelets earlier and potentially avoid bleeding complications.
She was careful to note that because the study findings are observational, they are “not definitive.” Yet they do support future “studies specifically focusing on female patients looking at the latest current guideline recommended strategies,” Kunadian added
‘It Has to Be Early’
So far, several studies haveshown discrepanciesin women’s care following acute MI compared with men, with data indicating that even an earlier invasive strategymight not bringequity in care. A newermachine learning-based scorehas shown promise in improving risk stratification for both men but especially women with NSTE ACS, but more work remains.
In anaccompanying editorial, Waqar H. Ahmed, MD (King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia), and Simone Biscaglia, MD (Ferrara University Hospital, Italy), say the findings should be discussed in light of the recent data from theSENIOR-RITAtrial, which found no difference in CV death or MI with conservative compared with invasive treatment in older adults with NSTE ACS. The trial did, however, observe a benefit with regard to nonfatal MI and repeat revascularization with invasive treatment over 4 years.
Notably, the mean time from admission to angiography in that study’s invasive arm was 5 days. It’s widely accepted that these patients will face delays to angiography if they present over the weekend or at non-PCI-capable hospitals, the editorialists write. “Findings of this meta-analysis support early angiography in those with GRACE scores > 140.”
Further, “the main merit” of the new data focusing on female patients confirms that “when an invasive strategy is warranted, it has to be early,” they say. “In addition, complete revascularization should be considered by means of coronary physiology to identify flow-limiting lesions and to avoid overtreatment.”