Dr.S.Venkatesan MD

EHJ has listed the top 10 papers in cardiology in the year 2022 in its current issue. 

Kindly go through this when free. While each of the 10 has its own importance, one meta-analysis, I thought was a  real bright spot. Though the message it conveys is nothing new,  it reaffirms an important management principle in ACS. Getting curious? Before going into the paper, a mini pretest

What is your take on these 4 statements on ACS?  True or False

1. STEMI is an emergency, NSTE-ACS* is not an emergency

2. Both are true emergencies.

3. STEMI is definite, yes, but  NSTE-ACS may or may not be (Mind the GRACE score dude !)

4. Even STEMI can be a non-emergency if the patient reports after 24 -48 hours.

(Remind you, NSTEACS = UA+NSTEMI , still often used interchangeably)

Hope we don’t have difficulty in identifying the wrong response. Whatever the answer to this somewhat insulting question to our intellect, forget it. Now, read this paper, which is listed as one of the most read last year. It is about the impact of early invasive strategy in NSTE-ACS.

Kite TA, Kurmani SA, Bountziouka . Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials. Eur Heart J. 2022 Sep 1;43(33):3148-3161.

Conclusion is pasted for the busy guys.

Post-test

1. What is overall NSTEMI in-hospital mortality? (Everyone knows for STEMI it is around 4-8 %, no one seems to be sure about NSTEMI. I think it can’t be estimated accurately, guess it is 1 -2% )
2. Is there a primary PCI equivalent situation in NSTEMI?  What are they? (Left main UA with AVR ST elevation comes first on the list)
3. Based on the urgency to treat how does the ultimate outcome change? (This is what this meta-analysis by Kite et all proved.It is not a new revelation though . Recall the landmark ICTUS study  of 2010 which was largely kept in the dark )

Final message

One lay definition of STEMI is, It is a mass of myocardium under fire. True UA/NSTEMI is, a mass of myocardium, that is threatening to go on fire. When firefighters are able to reach a smoky building before the onset of a fire, no doubt, it looks like a great & awesome response, Isn’t it? Unfortunately, the myocardial landscape is different and NSTEACS is such a heterogenous entity that doesn’t welcome unsolicited aggressive, emergency rescue missions. That’s one of the messages we get (at least I got )from this top-read paper in 2022. 

Reference

1.Emanuele Barbato, Margaret McEntegart, Tommaso Gori, The year in cardiovascular medicine 2022: the top 10 papers in interventional cardiology, European Heart Journal, 2023;, ehac778, https://doi.org/10.1093/eurheartj/ehac778

2.Kite TA, Kurmani SA, Bountziouka V, Cooper NJ, Lock ST, Gale CP, Flather M, Curzen N, Banning AP, McCann GP, Ladwiniec A. Timing of invasive strategy in non-ST-elevation acute coronary syndrome: a meta-analysis of randomized controlled trials. Eur Heart J. 2022 Sep 1;43(33):3148-3161.

3.Damman P, Hirsch A, Windhausen F, et al. 5-Year Clinical Outcomes in the ICTUS (Invasive versus Conservative Treatment in Unstable coronary Syndromes) Trial. J Am Coll Cardiol. 2010 Mar, 55 (9) 858–864.https://doi.org/10.1016/j.jacc.2009.11.026