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Unanswered Questions for Management of Acute Coronary Syndrome
Risk Stratification of Patients With Minimal Disease or Normal Findings on Coronary Angiography
Raffaele Bugiardini, MD;
Olivia Manfrini, MD;
Gaetano M. De Ferrari, MD
Arch Intern Med. 2006;166:1391-1395.
Background The prognostic implication of chest pain associated with normal or near-normal findings on angiography is still unknown. We explored outcomes and methods of risk stratification in patients with nonobstructive coronary artery disease in the setting of non–ST-segment elevation acute coronary syndromes.
Methods Data were pooled from 3 Thrombolysis in Myocardial Infarction (TIMI) trials (TIMI 11B, TIMI 16, and TIMI 22). Angiographic data were available on 7656 patients with non–ST-segment elevation acute coronary syndromes. The primary end point of this analysis was the composite of the rates of death, myocardial infarction, unstable angina requiring rehospitalization, revascularization, and stroke at 1-year follow-up. Outcomes were evaluated by mean of the TIMI risk score for developing at least 1 component of the primary end point.
Results Angiographic findings showed that 710 (9.1%) of 7656 patients had nonobstructive coronary artery disease; 48.7% of these had normal coronary arteries (0% stenosis), and 51.3% had mild coronary artery disease (>0% to <50% stenosis). A primary end-point event occurred in 101 patients (12.1%). It is noteworthy that a 2% event rate of deaths and myocardial infarctions had occurred in these patients at the 1-year follow-up. Event rates of death and myocardial infarction increased significantly as the TIMI risk score increased from 0.6% for a score of 1 to 4.0% for a score greater than 4.
Conclusions Patients with non–ST-segment elevation acute coronary syndromes with nonobstructive coronary artery disease detected by angiography have a substantial risk of subsequent coronary events within 1 year. The risk is not univariately high, and the TIMI risk score helps to reveal patients at high risk.
Author Affiliations: Department of Internal Medicine, Cardioangiology and Hepatology, University of Bologna, Italy (Drs Bugiardini and Manfrini); and Division of Cardiology, Coronary Unit, IRCCS Policlinico San Matteo, Pavia, Italy (Dr De Ferrari).
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