Analysis Of The Impact Of Invasive Intervention Timing On The Early Prognosis Of Non-ST-Segment Elevation Myocardial Infarction And Associated Factors

Background:The hospitalization rate for acute myocardial infarction(AMI)patients in China has been steadily increasing,largely driven by a rising proportion of non-ST-segment elevation myocardial infarction(NSTEMI)patients.These individuals typically present with older age,a higher percentage of females,and an elevated propensity for cardiovascular risk factors and comorbidities compared to their ST-segment elevation myocardial infarction(STEMI)counterparts.Hence,the management and treatment of NSTEMI patients pose a significant challenge.Invasive treatment has proven to significantly reduce mortality rates and major adverse cardiovascular events(MACEs)among NSTEMI patients,compared to conservative treatment strategies.However,the optimal timing for these invasive interventions remains a controversial.Thus,exploring the most effective timing for these interventions in NSTEMI patients is of paramount practical importance.Notably,revascularization rates among Chinese NSTEMI patients are significantly lower than those in Western countries,and the initiation of invasive treatment often encounters substantial delays,especially in relatively stable patients.To improve the prognosis of Chinese NSTEMI patients,this study aims to examine the impact of the timing of invasive interventions on early(3 0-day)outcomes,the factors associated with the occurrence of MACEs,and the variables linked with the decision for NSTEMI patients to undergo coronary angiography(CAG).We hope that our investigation can provide valuable clinical data to inform and improve the management of NSTEMI patients.Methods:The Evaluation and Management of Patients with Acute ChesT Pain in China(EMPACT)study is a prospective multicenter study that included 21 public hospitals in Shandong Province,spanning from August 2015 to September 2016.This study specifically recruited patients admitted in the emergency department with acute chest pain and symptoms indicative of acute coronary syndrome.For this investigation,we included patients diagnosed with NSTEMI in the EMPACT cohort between January 1,2016,and September 30,2017.Participants were classified based on the timing of their initial coronary angiography(CAG)after admission:no CAG,early CAG(<24 hours),and delayed CAG(≥24 hours).Furthermore,those undergoing percutaneous coronary intervention(PCI)were sub-divided into early PCI(<24 hours)and delayed PCI(≥24 hours)groups,according to the initial PCI time after admission.Demographic information,medical history,clinical features on admission,emergency medication treatment,bleeding events,intraoperative complications,and 30-day MACEs were collated.All statistical analyses were performed using SAS software(SAS Institute,Cary,NC,USA).Categorical variables were reported as numerical percentages and compared using the chi-square test or Fisher’s exact test,where suitable.Continuous variables that followed a normal distribution were expressed as mean±standard deviation and compared utilizing the t-test.In contrast,non-normally distributed continuous variables were reported as InterQuartile Range and compared using the Mann-Whitney U test.Multiple logistic regression model was applied to evaluate factors related to the incidence of MACEs in NSTEMI patients and factors associated with the decision for patients to undergo CAG,calculating the odds ratio(OR)and its 95%confidence interval(CI).A two-sided P value<0.05 was considered to represent a statistically significant difference.Results:A total of 969 NSTEMI patients met the inclusion criteria for this study,with 501 patients undergoing CAG[<24 hours,n=150(15.5%);≥24 hours,n=351(36.2%)].The 30-day incidence of MACEs among NSTEMI patients was 9.2%,including 54(5.6%)deaths.MACEs and mortality rates were lower in the CAG group compared with the non-CAG group(MACEs incidence:5.6%vs.13.0%,P<0.001;mortality rate:1.6%vs.9.8%,P<0.001).However,no statistically significant differences were observed between the early CAG and delayed CAG groups concerning MACEs and mortality rates.Similarly,no significant differences were found between the early percutaneous coronary intervention(PCI)and delayed PCI groups regarding MACEs and mortality rates.Furthermore,no statistically significant differences were identified in MACEs and mortality rates between the early and delayed CAG groups when NSTEMI patients were stratified by age,gender,and the presence of heart failure.Age[OR:1.036,95%CI(1.007,1.065),P=0.014]and concomitant acute heart failure[OR:2.431,95%CI(1.244,4.749),P=0.009]were identified as risk factors for MACEs in NSTEMI patients while undergoing CAG[OR:0.427,95%CI(0.219,0.832),P=0.012]or PCI[OR:0.376,95%CI(0.163,0.868),P=0.022]reduced the risk of MACEs.Additionally,age[OR:0.944,95%CI(0.932,0.957),P<0.001],presence of cardiogenic shock[OR:0.233,95%CI(0.079,0.629),P=0.009],pulmonary wet rales[OR:0.368,95%CI(0.197,0.686),P=0.002],and a history of chronic kidney disease[OR:0.070,95%CI(0.018,0.273),P<0.001]were factors influencing whether NSTEMI patients underwent CAG.Conclusions:(1)Compared with delayed invasive treatment,early invasive treatment did not reduce the 30-day incidence of major adverse cardiovascular events or mortality rates in NSTEMI patients;(2)Age and the presence of acute heart failure increased the risk of 30-day MACEs in NSTEMI patients while undergoing coronary angiography or percutaneous coronary intervention reduced this risk;(3)Factors influencing whether NSTEMI patients underwent CAG included age,the presence of cardiogenic shock,pulmonary wet rales,and a history of chronic kidney disease.