Copyright © 2000 by the European Society of Cardiology.
Treatment of Refractory Unstable angina in geographically isolated areas without Cardiac Surgery. Invasive versus conservative strategy (TRUCS Study)
University of Ioannina, School of Medicine, Department of Internal Medicine, Division of Cardiology, University Campus, Ioannina, Greece
revised July 21, 2000; accepted July 26, 2000
Abstract
Aims We compared invasive (on-site coronary angioplasty or emergency air-ambulance transfer for bypass grafting surgery) vs conservative (persistent medical treatment) strategies in the management of refractory unstable angina in geographically isolated hospitals without cardiac surgical facilities.
Methods and Results One hundred and forty eight randomized patients with refractory unstable angina were compared on an intention-to-treat basis. Outcomes (invasive vs conservative): (a) in hospital: stabilization (96% vs 43%,P =0·0001), non-fatal myocardial infarction (2·6% vs 4·2%, P=ns), death (1·3% vs 8·3%, P=0·046), combined outcome (3·9% vs 12·5%, P=0·053) and hospitalization (11·4±6·3 vs 12·4±8·0 days, P=ns). (b) 30-days follow-up: non-fatal myocardial infarction (2·6% vs 4·2%, P=ns), death (2·6% vs 11·1%,P =0·030) and combined outcome (5·3% vs 15·3%, P=0·031). (c) 12 month follow-up: non-fatal myocardial infarction (3·9% vs 4·2%, P=ns), death (3·9% vs 12·5%, P=0·053), combined outcome (7·9% vs 16·7%, P=ns), re-admissions for unstable angina: (17·1% vs 23·6%,P =ns), late coronary angioplasty: (15·8% vs 11·1%, P=ns) and (d) late coronary bypass grafting: (7·9% vs 12·5%,P =ns).
Conclusion Invasive treatment of patients with refractory angina in remote areas without surgical back-up results in significant in-hospital stabilization and a reduction in major events in-hospital and at 30 days. Coronary angioplasty in stand-alone units and air-transfer of these patients seems safe.
Key Words: Refractory unstable angina, angioplasty, surgical cover, air ambulance
Correspondence: Lampros K Michalis, Associate Professor of Cardiology, University of Ioannina, School of Medicine, Department of Internal Medicine, Division of Cardiology, University Campus, Ioannina GR 45110, Greece.
References
- Braunwald E, Jones RJ, Mark DB. Diagnosing and managing unstable angina. Circulation. 1994;90:613–622
[Abstract/Free Full Text] - Lange RA, Hillis LD. Should thrombolysis or primary angioplasty be the treatment of choice for acute myocardial infarction? N Engl J Med. 1996;335:1311–1312
[Free Full Text] - Zijlstra F, van't Hoff AWJ, Liem AL, Hoorntje JCA, Suryapranata H, de Boer MJ. Transferring patients for primary angioplasty: a retrospective analysis of 104 selected high risk patients with acute myocardial infarction. Heart. 1997;78:333–336
[Abstract/Free Full Text] - Windecker S, Meyer BJ, Bonzel T. Interventional cardiology in Europe 1994. Working Group Coronary Circulation of the European Society of Cardiology. Eur Heart J. 1998;19:40–54
[Abstract/Free Full Text] - McGrath PD, Malenka DJ, Wennberg DE. Changing outcomes in percutaneous coronary interventions: a study of 34752 procedures in northern New England, 1990 to 1997. Northern New England Cardiovascular Disease Study Group. J Am Coll Cardiol. 1999;34:674–680
[Abstract/Free Full Text] - Papaconstantinou HD, Marchall AJ, Burrell CJ. Diagnostic cardiac catheterisation in a hospital without on-site cardiac surgery. Heart. 1999;18:465–469
- Silber A, Albrecht A, Gohring S. Final annual report of practitioners of interventional cardiology in private practice in Germany. Results of procedures of left heart catheterization and coronary interventions in the year 1996. Herz. 1998;23:47–57[Web of Science][Medline]
- Ferrero V, Steffenino G, Meinardi F. Early aggressive treatment of unstable angina without cardiac surgical facilities: a prospective study of acute and long-term outcome. G Ital Cardiol. 1998;28:112–119[Medline]
- Weaver WD, Litwin PE, Martin JS. Use of direct angioplasty for treatment of patients with acute myocardial infarction in hospitals with and without on-site cardiac surgery. Circulation. 1993;88:2067–2075
[Abstract/Free Full Text] - Brodie BR. Primary angioplasty in a community hospital in the USA. Br Heart J. 1995;73:409–410
[Free Full Text] - Smyth DW, Richards AM, Elliott JM. Direct angioplasty in myocardial infarction in a hospital with surgical back-up 220 miles away. J Intervent Cardiol. 1997;9:324–332
- Wharton TP, McNamara NS, Fedele FA, Jacobs MI, Gladstone AR, Funk EJ. Primary angioplasty for the treatment of acute myocardial infarction: Experience at 2 community hospitals without cardiac surgery. J Am Coll Cardiol. 1999;33:1257–1265
[Abstract/Free Full Text] - Ryan TJ, Bauman WB, Kenedy JW. Guidelines for percutaneous transluminal coronary angioplasty. J Am Coll Cardiol. 1993;22:2033[Web of Science][Medline]
- Kirklin JW, Akins CW, Blackstone EH. Guidelines and indications for coronary bypass graft surgery. J Am Coll Cardiol. 1991;17:543[Web of Science][Medline]
- Circulation. 1994;89:1545–1556
[Abstract/Free Full Text] - Boden WE, O'Rourke RA, Crawford MH. Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators. N Engl J Med. 1998;338:1785–1792
[Abstract/Free Full Text] - Wallentin L, Lagerqvist B, Husted S, Kontny F, Stahle E, Swahn E. Outcome at 1 year after an invasive compared with a non-invasive strategy in unstable coronary-artery disease: the FRISC II invasive randomised trial. Lancet. 2000;356:9–16[CrossRef][Web of Science][Medline]
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