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CLINICAL RESEARCH: INVASIVE AND INTERVENTIONAL CARDIOLOGY

Impact of Delay to Angioplasty in Patients With Acute Coronary Syndromes Undergoing Invasive Management

Analysis From the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) Trial

Paul Sorajja, MD^_*, Bernard J. Gersh, MB, ChB, DPhil^_*, David A. Cox, MD, Michael G. McLaughlin, MD, Peter Zimetbaum, MD, Costantino Costantini, MD^#,_**, Thomas Stuckey, MD, James E. Tcheng, MD^||, Roxana Mehran, MD^#,_**, Alexandra J. Lansky, MD^#,_**, Cindy L. Grines, MD^¶ and Gregg W. Stone, MD^#,_**,_*

^_* Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
Beth Israel Deaconess Medical Center, Boston, Massachusetts
Mid Carolina Cardiology, Charlotte, North Carolina
Moses Cone Health System, Greensboro, North Carolina
^|| Duke University Medical Center, Durham, North Carolina
^¶ William Beaumont Hospital, Royal Oak, Michigan
^# College of Physicians and Surgeons, Columbia University Medical Center, New York, New York
^_** Cardiovascular Research Foundation, New York, New York

Manuscript received June 15, 2009; revised manuscript received October 7, 2009, accepted November 9, 2009.

^_* Reprint requests and correspondence: Dr. Gregg W. Stone, The Cardiovascular Research Foundation, 111 East 59th Street, 11th Floor, New York, New York 10022 (Email: gstone{at}crf.org).

Objectives: The aim of this study was to determine the impact of delay to angioplasty in patients with acute coronary syndromes (ACS).

Background: There is a paucity of data on the impact of delays to percutaneous coronary intervention (PCI) in patients with non–ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing an invasive management strategy.

Methods: Patients undergoing PCI in the ACUITY (Acute Catheterization and Urgent Intervention Triage strategY) trial were stratified according to timing of PCI after clinical presentation for outcome analysis.

Results: Percutaneous coronary intervention was performed in 7,749 patients (median age 63 years; 73% male) with NSTE-ACS at a median of 19.5 h after presentation (<8 h [n = 2,197], 8 to 24 h [n = 2,740], and >24 h [n = 2,812]). Delay to PCI >24 h after clinical presentation was significantly associated with increased 30-day mortality, myocardial infarction (MI), and composite ischemia (death, MI, and unplanned revascularization). By multivariable analysis, delay to PCI of >24 h was a significant independent predictor of 30-day and 1-year mortality. The incremental risk of death attributable to PCI delay >24 h was greatest in those patients presenting with high-risk features.

Conclusions: In this large-scale study, delaying revascularization with PCI >24 h in patients with NSTE-ACS was an independent predictor of early and late mortality and adverse ischemic outcomes. These findings suggest that urgent angiography and triage to revascularization should be a priority in NSTE-ACS patients.

Key Words: acute coronary syndrome • PCI • timing

Abbreviations and Acronyms   CABG = coronary artery bypass grafting   MI = myocardial infarction   NSTE-ACS = non–ST-segment elevation acute coronary syndrome   PCI = percutaneous coronary intervention   TIMI = Thrombolysis In Myocardial Infarction

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