19. Invasive vs. Conservative
• Invasive strategy is favoured over conservative
management
• Unresolved Issues –
– Optimal timing
– need to balance the risks of intervention for
unstable plaque
– risk of new ischemic events while waiting to
perform an invasive procedure
Milosevic A, et al. J Am Coll Cardiol Intv 2016
20.
21. Cumulative incidence of primary endpoint of death or MI at 30 days for
immediate versus delayed. Dashed black line intersecting the X axis denotes
the median time to angiography (61h) in patients undergoing delayed
invasive intervention Milosevic A, et al. J Am Coll Cardiol Intv 2016
22. Variable Immediate
Intervention
(n = 162)
Delayed
Intervention
(n = 161)*
HR (95% CI) p Value
30 days
Death or MI 4.3 13.0 0.32 (0.13–0.74) 0.008
Death, MI, or recurrent ischemia) 6.8 26.7 0.23 (0.12–0.45 <0.001
Death 3.1 3.1 0.98 (0.28–3.37) 0.97
MI 2.5 9.9 0.24 (0.08–0.70) 0.01
Recurrent ischemia 3.7 15.5 0.24 (0.10–0.57) 0.001
Major bleeding 0.6 0.6 0.99 (0.06–15.89) 0.99
31 days to 1 yr
Death or MI 2.6 6.5 0.39 (0.12–1.27) 0.12
Death, MI, or recurrent ischemia 9.3 9.3 0.99 (0.45–2.19) 0.71
Death§ 1.9 2.6 0.74 (0.17–3.31) 0.69
MI 0.6 4.3 0.15 (0.02–1.22) 0.07
Recurrent ischemia 6.5 2.2 2.99 (0.82–10.85) 0.06
Major bleeding 0.0 2.5 0.01 (0.01–46.38) 0.30
1 yr
Death or MI 6.8 18.8 0.34 (0.17–0.67) 0.002
Death, MI, or recurrent ischemia 15.4 33.1 0.28 (0.15–0.51) <0.001
Death 4.9 5.6 0.87 (0.34–2.26) 0.78
MI 3.1 13.8 0.21 (0.08–0.55) 0.002
Recurrent ischemia 9.9 16.9 0.28 (0.12–0.63) 0.002
Major bleeding 0.6 3.1 0.20 (0.02–1.68) 0.14
Clinical Outcomes Up to 1 Year
23. Cumulative incidence of the combined primary endpoint of death or new
myocardial infarction at 30 days and thereafter for patients undergoing
immediate versus delayed invasive intervention.
Milosevic A, et al. J Am Coll Cardiol Intv 2016
28. Conclusions
• Invasive treatment superior to conservative
• In high score immediate approach within 2
hours
• Biomarkers, recurrent ischemia, ECG and
hemodynamic changes determine the
approach
• Long term outcomes better in high risk