Standard threshold needed for revascularization in certain patients with non-STEMI

Harskamp RE. Am Heart J. 2014;167:355-362.e3.

  • March 3, 2014

Nearly 20% of patients who had non-STEMI and significant three-vessel or left main coronary disease were treated with medical management without revascularization in a recent study. Further, the wide variability observed across hospitals with this strategy suggested to researchers that there is no standard threshold for the use of revascularization in this patient population.

“Our study shows that even in hospitals with full revascularization capacities, [medical management strategy] is still frequently utilized for patients who are known to benefit the most from revascularization, namely those with [three-vessel disease], including those with significant left main involvement,” the researchers wrote.

In the study, researchers from the United States and the Netherlands included 42,535 patients from 423 US hospitals in the ACTION Registry – Get with the Guidelines from 2007 to 2012. Patients had not been treated with bypass surgery and had three-vessel disease (≥50% stenosis in all major coronary vessels) or left main disease (≥50% lesion) observed during in-hospital angiography. Researchers stratified hospitals (n=316) with an adequate volume (≥25 non-STEMI patients treated) into tertiles based on medical management strategy (MMS) use.

Overall, 17.6 % of patients were medically managed. The rate of patients treated with MMS varied from 16% to 19% each quarter and did not significantly change from 2007 to 2012 (P=.11). Researchers also reported a wide variation in patients treated with MMS at hospitals with adequate volume (median, 17.1%; P<.0001).

Hospital tertiles were similar in terms of patient baseline characteristics, predicted mortality risk, actual in-hospital mortality rates and discharge treatments.

“Since the use of MMS varies widely across hospitals despite a relatively similar hospital-level case mix, these findings suggest that there is no standard threshold for the use of revascularization in [non-]STEMI patients with [three-vessel disease]/[left main disease],” the researchers concluded.

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