An invasive strategy is beneficial in non ST-segment elevation acute coronary syndrome (NSTE-ACS). However, the optimal delay for performing the coronary angiogram (CA) in NSTE-ACS patients is unresolved especially in the absence of P2Y12-ADP-receptor inhibitor pretreatment.

To assess the impact of the delay of the invasive strategy in NSTE-ACS patients managed without pretreatment.

This analysis focuses on the subgroup of 80 patients included between 2016 and 2018 at Lille University Hospital in a prospective, randomized, controlled, open-label, parallel-group study. Patients were eligible if the diagnosis of intermediate- or high-risk NSTE-ACS is made and an invasive strategy intended. In the control group (DG, N=40), a delayed strategy is adopted with the CA between 12 and 72 hours after randomization. In the experimental group (EG, N=40), a very early invasive strategy was performed within 2 hours. The primary endpoint was the composite of cardiovascular (CV) death, myocardial infarction (MI), CV hospitalization, and recurrent ischemic event at 6 months.

The mean age was 61. The GRACE and CRUSADE scores were of 141.2 and 22.8, respectively in the EG. In the DG, they were of 144 and 25, respectively. In both groups, 23 patients (28.8%) had no significant coronary lesions at CA. The mean time between randomization and the CA was 1h in the EG and 25h in the DG. At 6 months, there was a trend for an increase in the composite primary endpoint in the EG as compared with the DG (15% vs. 32.5%, P=0.06). Among secondary endpoints, there was a significant difference in the rate of urgent revascularization that occurred in 15% of the DG patients vs. 2.5% of the EG patients (P=0.04).

Although no definitive conclusions could be drawn, an immediate invasive strategy was safe and feasible, and was associated with a trend of less ischemic events in intermediate- and high-risk NSTE-ACS patients managed without pretreatment.