Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients

Introduction: The European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation (NSTEMI) have recommended immediate (<2 hours) percutaneous coronary intervention (PCI) in very-high risk patients and early (<24 hours) PCI in high-risk patients. We aim to examine guidelines adherence in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS).

Material and method: All NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis. Patients’ risk stratification was performed according to the ESC guidelines.

Results and discussion: Out of 1,793 NSTEMI patients, 1,643 (92%) patients underwent PCI and in 1,078 the door to balloon time was documented. Of them, 155 (14%) and 923 (86%) patients were defined as very high-risk and high-risk NSTEMI patients, respectively. Of the very high-risk NSTEMI patients, only 9 (6%) underwent immediate coronary angiography and 50 (32%) underwent early coronary angiography. Acute heart failure 124 (80%) was the main reason for including NSTEMI patients in the very high-risk category. Of the high-risk patients, early coronary angiography was performed in only 406 (44%) patients. Patients in whom coronary angiography was postponed for more than 24 hours were older and had more comorbidities.

Conclusion: Our findings suggest that despite guidelines recommendations for immediate and early PCI in very high-risk and high-risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines non-adherence in those high-risk patients.