Patient characteristics Intervention Comparison Length of followup

Transcription

1 ISCHAEMIA TESTING CHAPTER TESTING FOR MYCOCARDIAL ISCHAEMIA VERSUS NOT TESTING FOR MYOCARDIAL ISCHAEMIA Ref ID: 4154 Reference Wienbergen H, Kai GA, Schiele R et al. Actual clinical practice exercise ing in consecutive patients after non-stelevation myocardial infarction: results the acute syndromes registry. Eur J Cardiovasc Prev Rehabil. 2006; 13(3): Study type/ Evidence level Observational Registry study (Cohort) Level 2+ Number patients N (NSTEMI) = 5281 Patient characteristics Intervention Comparison Length followup Inclusion: ACOS Registry: Consecutive patients between with acute syndrome presenting with NSTEMI. NSTEMI defined as persistent angina > 20 min; troponin T or I elevation; no ST-elevation (ECG could show ST-depression or T inversion, or could be normal) No exercise (N=4184) Exercise (N=1097) P value Mean age <0.01 Women <0.01 Prior MI Prior stroke / TIA Peripheral vascular disease Diabetes Mellitus Renal Failure Systemic hypertension Ejection fraction <40% < < < < <0.01 In hospital <0.01 Predischarge exercise N=1097 (20%) (78.2% treadmill echocardiography, 7.5% stress echocardiography, 12.5% stress scintigraphy, 1.8% no info on type exercise ) Mean duration hospital stay: 10 days No pre discharge exercise N=4184 One year measures All cause mortality, PCI and Coronary bypass surgery Source funding ACOS is supported by a grant from MSD

2 angiography or PCI In hospital PCI PCI<48h after admission < <0.01 People who had not had an exercise were significantly less likely to receive ASA, BB, statins pre-discharge than those who had an exercise. Effect Size 1 year follow up No exercise (N=4184) Exercise (N=1097) P value All cause mortality <0.01 PCI NS Coronary bypass surgery <0.01 Population No exercise Exercise Test P value No in hospital PCI One year mortality 18% 6.9% <0.01 (N=2872) In hospital PCI (N=2409) One year mortality 5.7% 2.2% <0.01 Logistic regression model factors strongly associated with a low rate exercise ing OR (95% CI) Ejection fraction <40% 0.53 ( ) Age >70 years 0.54 ( ) Prior Stroke / MI 0.61 ( ) Diabetes Mellitus 0.78 ( ) Sex, reperfusion therapy, beta blocker and statin therapy at discharge were also included in the model.

3 Ref ID: 4133 Reference Mehta RH, Rao SV, Ohman EM et al. Variation in the use stress ing and outcomes in patients with non-stelevation acute syndromes: insights from GUSTO IIb. Eur Heart J. 2008; 29(7): Study type/ Evidence level Cohort a GUSTO- 2B RCT comparing hirudin and UFH Level 2+ Number patients N= countries Patient characteristics Intervention Comparison Length followup Patients with NSTE ACS Stress (N=1878) No stress (N=6127) 67 (58-74) P value Age (median, IQR) 63 (54-70) <0.001 Female <0.001 Hypertension <0.001 Diabetes <0.001 Mellitus Current smoker <0.001 History <0.001 smoking Prior MI <0.001 Previous <0.001 angina Previous 8 11 <0.001 angioplasty Hyperlipidaemia Family history CAD Previous CABG Stress (23.5%) N=1878 (18% US and 26% non US countries) 70% electrocardiogram alone, 30% other ( echo, sestamibi, radionuclide angiography, thallium) 89% exercise ing, 11% pharmacological provocation Median time from enrolment to stress ing: 6 days No stress (76.5%) N=6127 One year measures Death or non fatal MI (or reinfarction) in the first 30 days follow up, death at 30 days and one year and MI (or reinfarction) at 30 days. Source funding Duke Clinical Research Institute

4 Angiography No angiography < Not reported Effect Size HR adjusted for age, gender, race, weight, US vs non-us site, hypertension, diabetes, hypercholesterolemia, history premature CAD, history angina, history PCI, CABG, smoking, CVD,, CHF, lung disease, CRI, PVD, BP at randomisation, HR, rales 6 month data available 7836 (98%) One year data available on 7300 (91%) outcome Stress (N=1878) No stress (N=6127) P value MI (30 days) <0.001 Death (30 days) <0.001 Death or MI (30 days) <0.001 Death (6 months) <0.001 Death or MI (6 months) 6 15 <0.001 Death, MI or revascularization (6 months) <0.001 Death, MI or revascularization (6 months) Kaplan Meier probability and 95% CI 0.19 ( ) 0.24 ( ) <0.001 Death (1 year) <0.001 Death (1 year) Kaplan Meier probability and 95% CI 0.03 ( ) 0.11 ( <0.001 Compared with no stress ing, stress ing is associated independently with the lower risk : 30-day death (adjusted HR: 0.47, 95% CI p=0.022) 30 day Death or MI (adjusted HR: 0.56, 95% CI p=0.004) 1 year mortality (adjusted HR: 0.58, 95% CI p=0.001) 30 day 1 year mortality (adjusted HR: 0.63, 95% CI p=0.008) Following exclusion pts with cardiac catheterization, MI, recurrent ischaemia, congestive heart failure or death in first 48hrs: 30-day death (adjusted HR: 0.52, 95% CI p=0.067 NS) 30 day Death or MI (adjusted HR: 0.61, 95% CI p=0.014) 1 year mortality (adjusted HR: 0.61, 95% CI p=0.007) 30 day 1 year mortality (adjusted HR: 0.65, 95% CI p=0.017) Composite end point death, MI or revascularization at 6 months was similar in both groups (adjusted HR: 0.99, 95% CI p=0.851 NS) Subgroup Analysis outcome Stress (no angiography) No stress (no angiography) Effect size (95% CI) (calculated by

5 (N=1061) (N=2404) RF) Death (6 months) OR 0.13 (0.08, 0.21) unadjusted Death or MI (6 months) OR 0.20 (0.14, 0.27) unadjusted Death, MI or revascularization (6 months) OR 0.50 (0.41, 0.60) unadjusted Death (1 year) OR 0.19 (0.13, 0.27) unadjusted