Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients: The RIDDLE-NSTEMI Study

Aleksandra Milosevic; Zorana Vasiljevic-Pokrajcic; Dejan Milasinovic; Jelena Marinkovic; Vladan Vukcevic; Branislav Stefanovic; Milika Asanin; Miodrag Dikic; Sanja Stankovic; Goran Stankovic

doi:10.1016/j.jcin.2015.11.018

Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients: The RIDDLE-NSTEMI Study

JACC Cardiovasc Interv. 2016 Mar 28;9(6):541-9. doi: 10.1016/j.jcin.2015.11.018. Epub 2016 Jan 6.

Affiliations

¹ Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Emergency Department, Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.
² Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
³ Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia.
⁴ Emergency Department, Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Institute for Medical Statistics and Informatics, Belgrade, Serbia.
⁵ Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
⁶ Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Emergency Department, Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia.
⁷ Center for Medical Biochemistry, Clinical Center of Serbia, Belgrade, Serbia.
⁸ Department of Cardiology, Clinical Center of Serbia, Belgrade, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia. Electronic address: gorastan@sbb.rs.

PMID: 26777321
DOI: 10.1016/j.jcin.2015.11.018

Abstract

Objectives: This study aimed to assess the clinical impact of immediate versus delayed invasive intervention in patients with non-ST-segment myocardial infarction (NSTEMI).

Background: Previous studies found conflicting results on the effects of earlier invasive intervention in a heterogeneous population of acute coronary syndromes without ST-segment elevation.

Methods: We randomized 323 NSTEMI patients to an immediate-intervention group (<2 h after randomization, n = 162) and a delayed-intervention group (2 to 72 h, n = 161).The primary endpoint was the occurrence of death or new myocardial infarction (MI) at 30-day follow-up.

Results: Median time from randomization to angiography was 1.4 h and 61.0 h in the immediate-intervention group and the delayed-intervention group, respectively (p < 0.001). At 30 days, the primary endpoint was achieved less frequently in patients undergoing immediate intervention (4.3% vs. 13%, hazard ratio: 0.32, 95% confidence interval: 0.13 to 0.74; p = 0.008). At 1 year, this difference persisted (6.8% in the immediate-intervention group vs. 18.8% in delayed-intervention group; hazard ratio: 0.34, 95% confidence interval: 0.17 to 0.67; p = 0.002). The observed results were mainly attributable to the occurrence of new MI in the pre-catheterization period (0 deaths + 0 MIs in the immediate-intervention group vs. 1 death + 10 MIs in the delayed-intervention group). The rate of deaths, new MI, or recurrent ischemia was lower in the immediate-intervention group at both 30 days (6.8% vs. 26.7%; p < 0.001) and 1 year (15.4% vs. 33.1%; p < 0.001).

Conclusions: Immediate invasive strategy in NSTEMI patients is associated with lower rates of death or new MI compared with the delayed invasive strategy at early and midterm follow-up, mainly due to a decrease in the risk of new MI in the pre-catheterization period. (Immediate Versus Delayed Invasive Intervention for Non-STEMI Patients [RIDDLE-NSTEMI]; NCT02419833).

Keywords: NSTEMI; delayed intervention; immediate intervention; randomized controlled trial.

Publication types

Comparative Study
Randomized Controlled Trial

MeSH terms

Aged
Coronary Angiography
Coronary Artery Bypass* / adverse effects
Coronary Artery Bypass* / mortality
Disease-Free Survival
Humans
Kaplan-Meier Estimate
Middle Aged
Non-ST Elevated Myocardial Infarction / diagnostic imaging
Non-ST Elevated Myocardial Infarction / mortality
Non-ST Elevated Myocardial Infarction / therapy*
Percutaneous Coronary Intervention* / adverse effects
Percutaneous Coronary Intervention* / mortality
Proportional Hazards Models
Recurrence
Risk Assessment
Risk Factors
Serbia
Time Factors
Time-to-Treatment*
Treatment Outcome

Associated data

ClinicalTrials.gov/NCT02419833