Time to coronary angiography in a real-life cohort of NSTEACS patients: are guidelines too optimistic?

Abstract Background and purpose In 2020, new recommendations against routine use of pretreatment in NSTEACS have been established, especially if an early invasive strategy (within first 24 hours) is planned [1]. These recommendations are mainly based on evidence from clinical trials that have included short intervals of time to coronary angiography (CA) [2,3]. However, this timing seems hard to achieve in daily clinical practice, above all, when high-risk NSTEACS patients are now advised for an early invasive strategy. We aimed to assess the feasibility of these recommendations in real-world clinical practice. Methods We performed a retrospective analysis of a real-life cohort of NSTEACS patients referred to CA in a tertiary-level hospital between January and December 2020. Results We analysed 347 consecutive NSTEACS patients referred to CA (21.7% unstable angina, 78.3% NSTEMI). Percutaneous coronary intervention was performed in 60.5% and the radial or cubital artery access were exclusively used in 86.7%. Median time from hospital admission to CA was 39.4 hours (IQR: 20.7–67.0 hours) and 31.4% patients had the CA performed within first 24 hours (Figure 1). Main differences regarding clinical and risk-related variables among those patients who underwent CA before and after first 24 hours are shown in Table 1. More patients with NSTEMI and dynamic changes in ECG tended to be referred earlier to CA, while those with impaired renal function were more likely to receive a delayed strategy. There were 282 patients (82.7%) who met the high-risk criteria from current ESC guidelines on NSTEACS (GRACE risk score >140, ST transient elevation or depression in ECG, raise of cardiac troponin levels above the 99th percentile of the upper reference limit, cardiogenic shock or cardiac arrest at presentation); of whom, only 95 (33.7%) were referred to CA in the first 24 hours. No differences were found according to patients being admitted to PCI or non-PCI centres (32.1% vs. 30.9% had the CA performed within first 24 hours, p=0.81) or receiving pretreatment with a P2Y12 receptor inhibitor or not (31.7% vs. 31.0% of the CA ≤24 hours group; p=0.87). Conclusion Evidence from this real-life registry shows that median time from admission to CA is far from current recommendations for high-risk NSTEACS patients. This might represent an important limitation at the moment of translating guidelines to daily clinical practice, especially those who presume patients to have a CA performed within first 24 hours. Funding Acknowledgement Type of funding sources: None.