Hinohara TT, et al. - Researchers assessed the outcomes of patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) who underwent downstream revascularization after initial medical management without revascularization. Findings reported that only a small proportion of patients initially managed medically after NSTE ACS required revascularization later. Compared to those not requiring downstream revascularization, a high rate of ischemic and major bleeding outcomes was observed in those who required downstream revascularization.

Methods

• In TRILOGY ACS, a total of 9,326 patients with NSTE ACS who were selected for medical management alone were included.
• These patients were randomly allocated to treatment with prasugrel or clopidogrel, and discharged without revascularization.
• Through 30 months, researchers compared patient characteristics and ischemic and bleeding outcomes between patients who underwent downstream revascularization after the index hospitalization and those who did not.

Results

• Later revascularization by percutaneous coronary intervention (73.1%), coronary artery bypass graft surgery (26.4%), or both (0.5%) was performed in 662 patients (7.1%).
• Data showed that median time to revascularization was 121 days (25th, 75^th percentiles: 41, 326) and revascularized patients, vs those not revascularized, were younger, more likely to be male, and had higher rates of hyperlipidemia, diabetes mellitus, prior myocardial infarction (MI), and prior revascularization.
• The highest rates of revascularization were reported in Europe and North America.
• During the follow-up period, a higher rate of the composite outcome of cardiovascular death, MI, or stroke occurring after revascularization was observed in those who underwent revascularization vs those not revascularized (hazard ratio [HR] 2.73 [95% confidence interval (CI) 2.21-3.38], p<0.001) as well as a higher rate of each of the individual outcomes.
• Among those who underwent revascularization, higher major bleeding was observed (GUSTO severe or life-threatening: HR 2.61 [95% CI 1.02-6.67], p=0.045; TIMI major: HR 2.24 [95% CI 1.12-4.48], p=0.022).
• Bleeding and ischemic outcomes did not vary by treatment with clopidogrel vs prasugrel.