Background: Whether treatment with revascularization versus medical management (MM) around the index hospitalization for non-ST-elevation acute coronary syndromes (NSTE ACS) influences the long-term, downstream use of revascularization is poorly defined. Our objective was to describe the incidence of follow-up coronary revascularization by initial treatment management in an international setting.
Methods: NSTE ACS patients enrolled in the IMPROVE-IT trial from 2005-2010 were compared based upon a clinical decision to use percutaneous coronary intervention within 30 days of randomization (early revascularization) versus medical management without revascularization (MM). Patients with CABG as part of their ACS management, or with planned CABG, were excluded. The frequencies of follow-up coronary revascularization >30 days from randomization through 7 years of follow-up were compared between groups.
Results: Altogether, 8212 of 12,514 NSTE ACS patients (65.6%) underwent PCI for management of initial ACS prior to randomization vs. 4302 (34.4%) who were treated with MM. The earlier revascularization patients were younger, more commonly male, and less commonly had diabetes mellitus and prior revascularization. The long-term crude incidence of follow-up revascularization procedures through 7 years was 26.4% in the earlier revascularization group (black line) vs. 17.5% in the MM group (red line) (p<0.001) (Figure). The earlier revascularization group also had a higher proportion of patients with >1 revascularization procedure during the follow-up period (6.3% vs. 3.1% for MM).
Conclusion: This post-hoc analysis of a clinically driven decision to pursue earlier revascularization in the IMPROVE-IT trial revealed initial earlier revascularization was associated with a 50% greater incidence of follow-up coronary revascularization compared with a decision to pursue initial medical management for patients who presented with an NSTE ACS event.