Clinical outcomes of invasive versus conservative strategies for very high-risk patients with non-ST-elevation acute coronary syndrome: an observational cohort study in a real-world population of China.

Abstract

Although an invasive strategy (IS) within 2 h is recommended for very high-risk patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), the optimal strategies remained debated due to a lack of evidence, because these patients were excluded from clinical studies. Therefore, we aimed to evaluate whether IS was associated with lower in-hospital and long-term all-cause death compared with conservative therapy among such patients, and whether the timing of IS differentially affected patient prognosis. This retrospective observational study recruited very high-risk patients with NSTE-ACS registered in the Chinese Cardiovascular Association Database-Chest Pain Centre between January 2015 and April 2021. Patients were grouped as receiving conservative therapy or IS within 2 h, 2-24 h, or >24 h after admission. The primary outcome was in-hospital all-cause death. Multivariable regression and inverse probability weighting analyses were conducted to account for measured confounding and assess the robustness of the findings. A total of 35,122 very high-risk patients with NSTE-ACS were finally included (mean age 64.2 years). Compared to the conservative strategy, IS at any time point (within 2 h, 2-24 h, >24 h) was associated with the reduced risk of in-hospital (adjusted odds ratio, 0.25-0.42, <i>P</i> < 0.001-0.009) and long-term all-cause death (median follow-up 551 days, adjusted hazard ratio, 0.33-0.45, <i>P</i> < 0.001). The incidence of in-hospital and long-term all-cause death did not differ significantly by IS timing. The inverse probability weighting analysis yielded consistent findings. For very high-risk patients with NSTE-ACS, IS was associated with a lower risk of in-hospital and long-term all-cause death compared to conservative strategy. However, among patients who underwent invasive management, mortality outcomes were broadly similar across different timings of IS. Further randomised controlled trials are warranted to verify this finding. This work was supported by High-level Hospital Construction Project and Basic and Applied Basic Research Fund of Guangdong Province.