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Original Contribution |

Immediate vs Delayed Intervention for Acute Coronary Syndromes:  A Randomized Clinical Trial FREE

Gilles Montalescot, MD, PhD; Guillaume Cayla, MD; Jean-Philippe Collet, MD, PhD; Simon Elhadad, MD; Farzin Beygui, MD, PhD; Hervé Le Breton, MD; Rémi Choussat, MD; Florence Leclercq, MD; Johanne Silvain, MD; François Duclos, MD; Mounir Aout, PhD; Jean-Luc Dubois-Randé, MD; Olivier Barthélémy, MD; Grégory Ducrocq, MD; Anne Bellemain-Appaix, MD; Laurent Payot, MD; Philippe-Gabriel Steg, MD; Patrick Henry, MD; Christian Spaulding, MD; Eric Vicaut, MD, PhD; for the ABOARD Investigators
[+] Author Affiliations

Author Affiliations: Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière (AP-HP), Université Paris 6, INSERM CMR 937, Paris (Drs Montalescot, Collet, Beygui, Choussat, Silvain, Barthélémy, and Bellemain-Appaix); Service de Cardiologie, Centre Hospitalier Universitaire Carémeau, Nîmes (Dr Cayla); Service de Cardiologie, Centre Hospitalier de Lagny–Marne la Vallée, Lagny-sur-Marne (Dr Elhadad); Service de Cardiologie et Maladies Vasculaires, INSERM U642, Université de Rennes 1, Centre Hospitalier Universitaire Rennes, Rennes (Dr Le Breton); Service de Cardiologie, Centre Hospitalier Universitaire Arnaud de Villeneuve, Montpellier (Dr Leclercq); Service de Cardiologie, Centre Hospitalier V. Dupouy, Argenteuil (Dr Duclos); Unité de Recherche Clinique (Drs Aout and Vicaut) and Service de Cardiologie (Dr Henry), Centre Hospitalier Universitaire Lariboisière (AP-HP), Université Paris, Paris; Service de Cardiologie, Centre Hospitalier Universitaire H. Mondor (AP-HP), Créteil (Drs Aout, Dubois-Randé, and Vicaut); INSERM U-698 and Service de Cardiologie, Centre Hospitalier Universitaire Bichat-Claude Bernard (AP-HP), Paris (Drs Ducrocq and Steg); Service de Cardiologie, Centre Hospitalier Intercommunal A. Grégoire, Montreuil-sous-Bois (Dr Payot); Service de Cardiologie, Centre Hospitalier Cochin (AP-HP), INSERM U909, Université Paris-Descartes, Paris (Dr Spaulding), France.


JAMA. 2009;302(9):947-954. doi:10.1001/jama.2009.1267.
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Published online

Context International guidelines recommend an early invasive strategy for patients with high-risk acute coronary syndromes without ST-segment elevation, but the optimal timing of intervention is uncertain.

Objective To determine whether immediate intervention on admission can result in a reduction of myocardial infarction compared with a delayed intervention.

Design, Setting, and Patients The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, a randomized clinical trial that assigned, from August 2006 through September 2008 at 13 centers in France, 352 patients with acute coronary syndromes without ST-segment elevation and a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or more to receive intervention either immediately or on the next working day (between 8 and 60 hours after enrollment).

Main Outcome Measures The primary end point was the peak troponin value during hospitalization; the key secondary end point was the composite of death, myocardial infarction, or urgent revascularization at 1-month follow-up.

Results Time from randomization to sheath insertion was 70 minutes with immediate intervention vs 21 hours with delayed intervention. The primary end point did not differ between the 2 strategies (median [interquartile range] troponin I value, 2.1 [0.3-7.1] ng/mL vs 1.7 [0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The key secondary end point was observed in 13.7% (95% confidence interval, 8.6%-18.8%) of the group assigned to receive immediate intervention and 10.2% (95% confidence interval, 5.7%-14.6%) of the group assigned to receive delayed intervention (P = .31). The other end points, as well as major bleeding, did not differ between the 2 strategies.

Conclusion In patients with acute coronary syndromes without ST-segment elevation, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in myocardial infarction as defined by peak troponin level.

Trial Registration clinicaltrials.gov Identifier: NCT00442949

Figures in this Article

The optimal intervention in the treatment strategy of patients presenting with acute coronary syndromes without ST-segment elevation (NSTE-ACS) has been debated for years. Numerous studies, randomized trials, and meta-analyses have investigated the potential benefits of invasive over conservative strategies, and most have suggested a prolonged advantage of an invasive approach for the prevention of death or myocardial infarction (MI), particularly among high-risk patients.114

If an invasive strategy is generally accepted to be the best option and is currently recommended in high-risk patients, little information is available regarding the optimal timing of coronary angiography and intervention.15,16 Only 2 randomized studies evaluated the timing of intervention (early vs late) with patients in the 2 study groups receiving comparable antithrombotic and invasive therapy.10,12 The Intracoronary Stenting With Antithrombotic Regimen Cooling Off (ISAR-COOL) study showed that early angiography (mean time to catheterization, 3 hours) was superior to delayed angiography (4 days) in preventing death or MI at 1-month follow-up. In contrast, the recent Timing of Intervention in Patients With Acute Coronary Syndromes (TIMACS) study showed no advantage of early catheterization (14 hours) over late catheterization (50 hours) to prevent death, MI, or stroke at 6-month follow-up. The ISAR-COOL study had a long waiting period for catheterization in the control group, which is probably not fully representative of contemporary practice in high-volume centers with expedited care, whereas the “early” group in the TIMACS study had a longer delay to angiography than those in previous studies that also investigated a rapid invasive approach.8,10,11

Most high-volume centers have primary percutaneous coronary intervention (PCI) programs for acute ST-segment elevation myocardial infarction, a strategy that has been associated with improved outcome in these patients.17 The same centers usually perform rapid catheterization for NSTE-ACS, in general on the day following admission. Whether further reduction in the time to intervention could reduce the occurrence of ischemic events is an attractive hypothesis but is so far unverified. In this study, we compared a strategy of immediate intervention mimicking a primary PCI approach to NSTE-ACS with a strategy of intervention scheduled on the next working day.

Study Population

The Angioplasty to Blunt the Rise of Troponin in Acute Coronary Syndromes Randomized for an Immediate or Delayed Intervention (ABOARD) study, conducted from August 2006 through September 2008, enrolled patients with NSTE-ACS admitted at 13 high-volume centers in France with 24-hour facilities for treatment of primary PCI. The protocol was approved by the Comité de Protection des Personnes Ile-de France IV. The trial was led by the Academic Research Organization ACTION, the coordinating center being the Institut de Cardiologie at Pitié-Salpêtrière Hospital. Data management and statistical analyses were under the responsibility of the Unité de Recherche Clinique at Lariboisière Hospital. The trial was sponsored by the Direction de la Recherche Clinique at Assistance Publique-Hôpitaux de Paris (AP-HP) and mainly funded by a public grant from the Programme Hospitalier de Recherche Clinique.

Non–ST-segment elevation ACS was defined by the presence of at least 2 of the following criteria: (1) symptoms of myocardial ischemia, (2) electrocardiographic ST-segment abnormalities (depression or transient elevation of at least 0.1 mV) or T-wave inversion in at least in 2 contiguous leads, or (3) an elevated cardiac troponin I value (above the upper limit of normal). Eligible patients had to have also a Thrombolysis in Myocardial Infarction (TIMI) score of 3 or greater and an indication for coronary angiography. Main exclusion criteria were age younger than 18 years; refractory ischemia, major arrhythmias, or hemodynamic instability requiring immediate catheterization; ongoing treatment with warfarin, fibrinolysis, or glycoprotein IIb/IIIa inhibitor; and contraindications to abciximab. All patients provided written voluntary informed consent.

Randomization and Interventions

At admission, patients were centrally randomized with the use of a telephone Interactive Voice Randomization System to undergo an immediate invasive strategy or an invasive strategy scheduled on the next working day. Next working day was defined by a time window of 8 to 60 hours after enrollment, so that catheterization could be scheduled on the next calendar day for weekday admissions and on Mondays for weekend admissions. Decisions regarding the method for revascularization were left to the discretion of the investigators. In the 2 groups, when PCI was believed appropriate on the basis of the coronary angiogram, the investigators were asked to perform culprit vessel PCI in the same setting. In case of multivessel PCI, nonculprit vessels could be revascularized in the same setting or in a staged fashion, according to investigator preferences. In the 2 groups, when PCI was decided, abciximab treatment had to be started before wire-crossing of the lesion, using specific trial-labeled abciximab. When revascularization with coronary artery bypass graft (CABG) surgery was preferred, it was to be performed as soon as possible during the initial hospitalization period, regardless of randomized group.

Medical Therapy and Follow-up

Antithrombotic treatments respected local practice of the participating centers but were to be identical in the 2 study groups. Aspirin was recommended with an initial high loading dose of up to 500 mg, followed by 75 mg once daily. A high clopidogrel loading dose of more than 300 mg was also recommended, followed by 75 to 150 mg once daily. Choice and dose of anticoagulant were left to the discretion of the investigators. In patients undergoing PCI, abciximab was started just before intervention, with a 0.25-mg/kg intravenous bolus immediately followed by a 0.125-μg/kg per minute (to a maximum of 10 μg/min) continous intravenous infusion for 12 hours after completion of PCI. β-Blockers, statins, and angiotensin-converting enzyme inhibitors were strongly recommended as concomitant treatments. Patients underwent 12-lead electrocardiography before and after revascularization. Blood samples were taken every 6 hours before and after intervention (up to 24 hours after intervention or discharge) for measurement of troponin I and creatine kinase or creatine kinase MB values. Blood sampling was repeated in case of recurrent ischemic episode during hospitalization. Measurements were performed locally, and the centers were requested to provide their value for the 99th percentile of the distribution curve of values obtained in a healthy population, as has been advocated for several years.18 All biomarker values collected in each randomized patient were entered in a computer database for further analysis. One-month follow-up data were collected through a patient visit or, if not possible, by telephone interview.

Outcome Measures

The primary end point was the peak troponin I value during hospitalization for each patient. The key secondary end point was a composite of death, MI, or urgent revascularization at 1-month follow-up. Death was defined as death from any cause. Myocardial infarction was defined as any recurrent myocardial necrosis occurring either spontaneously or in the setting of revascularization. Recurrent myocardial necrosis was defined by the occurrence of any of the following: new Q waves in 2 or more contiguous electrocardiographic leads; spontaneous or post-PCI elevation of levels of creatine kinase and its MB isoenzyme to at least 2 times the upper limit of normal, with an increase of 50% or more over the previous value (if only creatine kinase values were available, the same rule applied, but a simultaneous increase in troponin I level was required); post-CABG elevation of levels of creatine kinase and its MB isoenzyme to at least 5 times the upper limit of normal, with an increase of 50% or more over the value obtained before operation (if only creatine kinase values were available, the same rule applied but a simultaneous increase in troponin level was required).

Major bleeding included spontaneous, PCI-related, or CABG-related bleeding. Major bleeding was defined according to the STEEPLE definitions,19 by the presence of at least 1 of the following: bleeding resulting in death; retroperitoneal bleeding (confirmed by ultrasound, magnetic resonance imaging, computed tomography, surgery, or autopsy), intracranial bleeding (documented with magnetic resonance imaging, computed tomography, any other examination or autopsy), or intraocular bleeding; bleeding with hemodynamic compromise requiring specific treatment (inotropic drugs, administration of fluid or macromolecules); bleeding requiring surgical intervention or decompression of a closed space to stop or control the event (vascular surgery, drainage of cardiac tamponade); any transfusion of at least 1 unit of red blood cells or whole blood; or clinically overt bleeding resulting in a 3-g/dL decrease in hemoglobin value (or, when hemoglobin values were not available, a 10% decrease in hematocrit). Thrombocytopenia was defined as a platelet count less than 50000 cells/μL or a decrease of more than 50% from the admission value. End points were adjudicated by a central committee unaware of the treatment assignments of the patients.

Statistical Analysis

We calculated that a sample size of 176 in each group would ensure a power of at least 80% to detect a difference in peak troponin I values between the 2 strategies if the effect size (ratio of difference to standard deviation) was 0.3, using a t test, with a bilateral risk set at 5%. On this basis, the trial enrolled 352 patients. Analysis was by intention-to-treat. In case of missing values, a sensitivity analysis was carried out to check the robustness of the conclusions. Since the statistical distribution of the main criterion was found to be non-gaussian (tested by Shapiro-Wilk test), the Mann-Whitney test was used to compare the 2 strategies, and median differences associated to Hodges-Lehman 95% confidence interval (CI) were used to estimate differences between strategies for the whole population and for subgroups. All secondary end points were qualitative variables, and differences were tested by χ2 or by Fisher exact probability tests if the validity criteria for the χ2 test were not fulfilled. All tests were 2-sided, with a significance level fixed at 5%. All analyses were performed using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina).

Patient Characteristics

Three hundred fifty-two patients were randomly assigned to undergo immediate or delayed intervention at 13 French centers with primary PCI facilities. Baseline characteristics were well balanced between treatment groups (Table 1). As expected from the enrollment criteria, many patients presented with comorbid conditions (95 [27%] with diabetes, 261 [74%] with elevated troponin I level, and 94 [27%] with TIMI score ≥5 on a maximum scale of 7). The patients received optimal medical therapy, which was similar in the 2 study groups, including statins in 333 (95%), β-blockers in 303 (86%), angiotensin-converting enzyme inhibitors in 289 (83%), and intense antiplatelet therapy as shown by high doses of clopidogrel and abciximab in 221 (99%) of patients undergoing PCI. Low-molecular-weight heparin was the most common anticoagulation prescribed. One-month follow-up was obtained in all patients.

Table Graphic Jump LocationTable 1. Baseline Patient Characteristics
Procedure Characteristics

Median time from randomization to sheath insertion was 70 (interquartile range [IQR], 0.51-123) minutes in the immediate intervention group, reflecting a primary PCI approach, compared with 21 (IQR, 18-25) hours in the delayed intervention group, confirming that intervention in this group was most often performed on the day following randomization. A coronary angiogram was obtained in all but 1 patient (Figure 1). Arterial access was radial in 296 patients (84%), multivessel disease was present in 178 patients (60%), and the left anterior descending artery was most frequently identified as the culprit artery. Percutaneous coronary intervention was performed in 222 (75%) and CABG in 33 (11%) patients with significant lesions on the coronary angiogram; on average, patients undergoing PCI received 1.2 (SD, 0.9) stents, of which 51% were drug-eluting stents (Table 2).

Place holder to copy figure label and caption
Figure 1. Trial Flow
Graphic Jump Location
Table Graphic Jump LocationTable 2. Delays and Results of Cardiac Procedures
Main Outcome

Troponin I release, as reflected by peak value collected during hospitalization, did not differ between the 2 strategies (median, 2.1 [IQR, 0.3-7.1] ng/mL vs 1.7 [IQR, 0.3-7.2] ng/mL in the immediate and delayed intervention groups, respectively; P = .70). The probability of MI as measured by the curves of troponin peak values was similar with either strategy (Figure 2). Consistent results were found across all major subgroups (Figure 3). In the subset of revascularized patients, the proportion of peak troponin values occurring before the procedure was 109 (43.4%; 95% CI, 37.3%-49.6%), whereas the proportion of peak troponin values occurring after the procedure was 142 (56.6%; 95% CI, 50.4%-62.7%).

Place holder to copy figure label and caption
Figure 2. Peak Troponin I Values (Primary End Point) in Groups Receiving Immediate and Delayed Invasive Intervention
Graphic Jump Location

Curves represent probability density function of the peak troponin value (for each value x of troponin, density is the probability for troponin value to be in the interval [x, x + dx]).

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Figure 3. Primary End Point (Peak Troponin I Value) in Relevant Subgroups
Graphic Jump Location

Boxes indicate median (interquartile range); whiskers, 10th and 90th deciles. TIMI indicates Thrombolysis in Myocardial Infarction.

Secondary Outcomes

The key secondary end point combining death, MI, or urgent revascularization at 1-month follow-up occurred in 13.7% (95% CI, 8.6%-18.8%) of patients with the immediate strategy and 10.2% (95% CI, 5.7%-14.6%) of patients with the delayed strategy (P = .31). Because 5 patients (2 in the immediate group and 3 in the deferred group) did not come for the 1-month visit, we checked that similar conclusions were drawn when the secondary end points for these patients were considered not reached (Table 3) or reached (data not shown).

The incidence of the 3 components taken individually through 30 days was not significantly different between the 2 groups (Table 3). Of the 24 MIs, 9 occurred before and 15 after catheterization. When a different definition of MI was tested, using 5 times the upper limit of normal of creatine kinase MB with an increase of 50% or more over the previous value, no significant difference was observed between the 2 strategies (n = 7 [4%] vs n = 3 [1.7%], P = .22). The neutral effect of intervention observed overall for the key secondary end point was also consistent across all major subgroups. When the analyses were restricted to revascularized patients, no significant difference was observed between the 2 strategies for both the primary and secondary end points. To exclude that long delays to the catheterization laboratory would bias the results toward the negative, we performed a sensitivity analysis confirming that results and conclusions reported in Table 3 were similar when patients of the deferred group with a time to the catheterization laboratory in the greater than 75th percentile were excluded.

Recurrent ischemia was not significantly lower with the immediate strategy than with the delayed approach (12.0% [95% CI, 7.2%-16.8%] vs 18.6% [95% CI, 12.9%-24.4%], respectively; P = .08), and the composite quadruple end point of death, MI, urgent revascularization, or recurrent ischemia occurred in 21.1% (95% CI, 15.1%-27.2%) and 21.5% (95% CI, 15.4%-27.5%) of patients, respectively (P = .94).

Hospital stay was significantly reduced with the immediate strategy compared with the delayed intervention strategy (median, 55 [IQR, 30-98] hours vs 77 [IQR, 49-145] hours, respectively; P < .001).

Safety Outcomes

There was no difference in major bleeding between the 2 groups (Table 3). Nineteen patients presented with major bleeding, CABG or non-CABG related, with or without transfusion. The most frequent overt bleeding complications were gastrointestinal tract (n = 4) and puncture-related (n = 4, all groin hematomas) bleeding; other bleeding complications were hemopericardium (n = 2), intracranial (n = 1), epistaxis (n = 1), and non-access site–related hematoma (n = 1). One of these patients had 2 bleeding events. Seven more patients had no clinical evidence of bleeding but presented either a decrease in hemoglobin level during hospitalization or had anemia on admission motivating a transfusion; these patients were then counted as having major bleeding.

This study demonstrates the feasibility of immediate catheterization and revascularization in patients who present with NSTE-ACS but does not show that this strategy is superior to catheterization scheduled on the next working day. The hypothesis that reducing the waiting period for revascularization to a delay of primary PCI would reduce MI is not confirmed. To our knowledge, the mean time to catheterization in our delayed intervention group is also the shortest time to catheterization ever reported in the conservative group of randomized studies, but we believe it accurately reflects current practice in high-volume centers performing expedited care for patients with NSTE-ACS. There was no suggestion of a possible benefit with the strategy of immediate catheterization in any subgroup, including the highest-risk subgroups.

One concern with studies comparing different strategies of intervention in NSTE-ACS is the frequent imbalance in rates of catheterization, revascularization, and medications used. Moreover, rapid percutaneous revascularization may expose stented patients to ineffectiveness of some medications that have a slow onset of action. These limitations may not apply to our study, because all patients in the 2 groups underwent catheterization, leading to comparable rates of revascularization. In all patients, we used high loading doses of clopidogrel, reducing its slow onset of action; when PCI was performed, immediate and strong platelet inhibition was provided with the administration of abciximab, a strategy of intense antiplatelet therapy comparable to what is recommended in primary PCI and what has been shown effective in treatment of high-risk NSTE-ACS.20 A recent study has confirmed that glycoprotein IIb/IIIa inhibitors should not be routinely administered at admission in NSTE-ACS but rather initiated after angiography, a strategy applied in our study.21

The benefit of early intervention in NSTE-ACS relates directly to the patient's level of risk as evaluated by the Global Registry of Acute Coronary Events (GRACE) score in TIMACS, the TIMI score in our study, and more intuitively in ISAR-COOL.10,12 The magnitude of clinical benefit in these studies also correlates with the difference in time to catheterization between the 2 strategies—long in ISAR-COOL (83 hours), intermediate in TIMACS (36 hours), and short in ABOARD (19 hours). According to all 3 studies, an early invasive approach is no better than a delayed approach at preventing death; it also has little effect on MI, while there is a modest reduction in episodes of refractory ischemia. Thus, rapid or urgent catheterization appears preferable in high-risk or unstable patients, while the benefit in other situations may be limited to practicality and length of hospital stay.

Many different definitions of MI have been used in prior studies, using different cutoff levels of creatine kinase MB: the upper limit of normal,4,5 greater than 2 times the upper limit of normal,9,22 or greater than 3 times the upper limit of normal.7 The upper limit of normal of troponin I level has also been used in the definitions of MI in more recent recent trials.23 We designed our study following the recommendations of the European Society of Cardiology,18 with a definition of MI based on troponin value for the primary end point, a recommendation confirmed during the study by the publication of the Joint Task Force for the Redefinition of Myocardial Infarction.24 We used the peak troponin value during hospitalization, occurring before or after revascularization, knowing that periprocedural myonecrosis and spontaneous or recurrent myonecrosis both have prognostic implications.2527 The peak troponin value is also rarely missed in patients with NSTE-ACS and is certainly a better end point in this study than the area under the curve, which is directly affected by the delay to catheterization. Using intense antiplatelet therapy and comparing immediate to delayed intervention, we could not demonstrate a significant difference in MI, regardless of the definition of MI based on peak troponin (primary end point) or peak creatine kinase MB (secondary end point) values. Recurrent ischemia as well as urgent revascularization was numerically lower with the immediate strategy, but these differences did not reach statistical significance. Such favorable trends with early intervention are consistent with those from other studies, which had different timings for revascularization.10,12

The safety of immediate intervention was not different from that of delayed intervention. We used the STEEPLE definitions of major bleeding, because they are more sensitive than other bleeding definitions and are more adapted to percutaneous intervention. The predominant use of radial access in our multicenter intervention study limited the number of access-site complications.28,29 Gastrointestinal tract bleeding was the most frequent complication and was possibly underestimated, because occult gastrointestinal tract bleeding also may have occurred in some of the 7 patients who had anemia or a decrease in hemoglobin level without overt bleeding.

The use of optimal medical therapy was higher in our study than that reported in registries, which may appear as a limitation and could influence effectiveness in clinical practice. Additionally, the study sample size, like that in other studies, limited the ability to arrive at a definite conclusion regarding a difference in clinical events.6,8,10,11,30 Nevertheless, the strategy of immediate intervention does not appear to provide any benefit or harm in comparison with an intervention postponed to the next working day; it was, however, associated with a significantly shorter hospital stay. A large majority of patients with NSTE-ACS remain free of complications, and after successful percutaneous revascularization, nothing should hamper hospital discharge. In general, conservative strategies consume considerable resources, drugs, and physician and nursing time, and this shortening in hospital stay may appear to be a practical and economic advantage in high-volume centers with a rapid turnover, especially when the patients present during daytime and catheterization rooms are already activated. However, further economic analyses would be required to assess the cost-effectiveness of such strategy in various health care systems.

In patients with moderate- to high-risk NSTE-ACS, a strategy of immediate intervention compared with a strategy of intervention deferred to the next working day (mean, 21 hours) did not result in a difference in MI as defined by peak troponin level.

Corresponding Author: Gilles Montalescot, MD, PhD, Institut de Cardiologie, Bureau 2-236, Centre Hospitalier Universitaire Pitié-Salpêtrière, 47 Boulevard de l’Hôpital, 75013 Paris, France (gilles.montalescot@psl.aphp.fr).

Author Contributions: Dr Montalescot had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Montalescot, Le Breton, Spaulding, Vicaut.

Acquisition of data: Montalescot, Collet, Elhadad, Beygui, Le Breton, Choussat, Leclercq, Silvain, Duclos, Aout, Dubois-Randé, Barthélémy, Ducrocq, Bellemain-Appaix, Payot, Steg, Henry.

Analysis and interpretation of data: Montalescot, Cayla, Silvain, Aout, Steg, Spaulding, Vicaut.

Drafting of the manuscript: Montalescot, Choussat, Aout, Vicaut.

Critical revision of the manuscript for important intellectual content: Cayla, Collet, Elhadad, Beygui, Le Breton, Leclercq, Silvain, Aout, Dubois-Randé, Barthélémy, Ducrocq, Bellemain-Appaix, Payot, Steg, Henry, Spaulding, Vicaut.

Statistical analysis: Silvain, Aout, Vicaut.

Obtained funding: Montalescot, Leclercq, Silvain, Vicaut.

Administrative, technical, or material support: Montalescot, Beygui, Barthélémy, Ducrocq, Bellemain-Appaix, Henry, Vicaut.

Study supervision: Montalescot, Collet, Beygui, Le Breton, Silvain, Dubois-Randé, Spaulding.

Financial Disclosures: Dr Montalescot reported receiving research grant support, consulting fees, and lecture fees from Bristol-Myers Squibb, Daichi-Sankyo, Eli Lilly, and Sanofi-Aventis; consulting fees and lecture fees from AstraZeneca and The Medicines Company; consulting fees from Novartis and Schering-Plough; and lecture fees from Pfizer. Dr Collet reported receiving research grants from Bristol-Myers Squibb, Sanofi-Aventis, Eli Lilly, Guerbet Medical, Medtronic, Boston Scientific, Cordis, Stago, Centocor, Fondation de France, INSERM, Federation Francaise de Cardiologie, and Societe Francaise de Cardiologie; consulting fees from Sanofi-Aventis, Eli Lilly, and Bristol-Myers Squibb; and lecture fees from Bristol-Myers Squibb, Sanofi-Aventis, and Eli Lilly. Dr Sylvain reported receiving research grants from Daichi-Sankyo, Eli Lilly, and Sanofi-Aventis. Dr Steg reported receiving research grants from Sanofi-Aventis; serving on the speakers bureau for Boehringer-Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Medtronic, Nycomed, Sanofi-Aventis, Servier, and The Medicines Company; receiving consulting fees from Astellas, AstraZeneca, Bayer, Boehringer-Ingelheim, Bristol-Myers Squib, Daiichi-Sankyo, Endotis, GlaxoSmithKline, Medtronic, Merck Sharp & Dohme, Nycomed, Sanofi-Aventis, Servier, and The Medicines Company; and holding stock in Aterovax. Dr Spaulding reported receiving research grant support from Cordis; speaker fees from Cordis, Abbott, Eli-Lilly, and Sanofi-Aventis; and consulting fees from Cordis. Dr Vicaut reported receiving research grant support and consulting fees from Pfizer, Stallergène, and Innothera and consulting fees from AstraZeneca, Sanofi-Aventis, Abbott, and Servier. No other authors reported disclosures.

Funding/Support: This study was primarily funded by the Programme Hospitalier de Recherche Clinique (French Ministry of Health); sponsored by Assistance Publique-Hopitaux de Paris (AP-HP); led by the A.C.T.I.O.N. group (Academic Research Organization); Coordinating Center: Pitié-Salpêtrière University Hospital; Data Management and Statistics: Unité de Recherche Clinique, Lariboisière University Hospital. Eli Lilly provided an unrestricted research grant as well as the abciximab used for the study.

Role of the Sponsors: The Assistance Publique-Hopitaux de Paris (AP-HP) and Eli Lilly had no role in the design and conduct of the study; the collection, analysis, and interpretation of the data; or the preparation, review, or approval of the manuscript.

Additional Contributions: We thank the investigators and research coordinators of the following centers for their participation in the ABOARD study: Institut de Cardiologie, Centre Hospitalier Universitaire Pitié-Salpêtrière, Paris; Service de Cardiologie, Centre Hospitalier Universitaire Carémeau, Nîmes; Service de Cardiologie, Centre Hospitalier de Lagny- Marne la Vallée, Lagny-sur-Marne; Service de Cardiologie, Centre Hospitalier Universitaire Pontchaillou, Rennes; Service de Cardiologie, Centre Hospitalier Universitaire Arnaud de Villeneuve, Montpellier; Service de Cardiologie, Centre Hospitalier V. Dupouy, Argenteuil; Unité de Recherche Clinique, Centre Hospitalier Universitaire Lariboisière, Paris; Service de Cardiologie, Centre Hospitalier Universitaire H. Mondor, Créteil; Service de Cardiologie, Centre Hospitalier Universitaire Bichat-Claude Bernard, Paris; Service de Cardiologie, Centre Hospitalier Intercommunal A. Grégoire, Montreuil-sous-Bois; Service de Cardiologie, Centre Hospitalier Universitaire Lariboisière, Paris; Service de Cardiologie, Centre Hospitalier Universitaire Cochin-Port-Royal, Paris; Service de Cardiologie, Centre Hospitalier Universitaire Saint- Antoine, Paris; Service de Cardiologie, Centre Hospitalier Universitaire A. Paré, Paris.

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PubMed   |  Link to Article
de Winter RJ, Windhausen F, Cornel JH,  et al; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators.  Early invasive versus selectively invasive management for acute coronary syndromes.  N Engl J Med. 2005;353(11):1095-1104
PubMed   |  Link to Article
Michalis LK, Stroumbis CS, Pappas K,  et al.  Treatment of refractory unstable angina in geographically isolated areas without cardiac surgery: invasive versus conservative strategy (TRUCS study).  Eur Heart J. 2000;21(23):1954-1959
PubMed   |  Link to Article
Cannon CP, Weintraub WS, Demopoulos LA,  et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators.  Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.  N Engl J Med. 2001;344(25):1879-1887
PubMed   |  Link to Article
Spacek R, Widimsky P, Straka Z,  et al.  Value of first day coronary angiography/angioplasty in evolving non–ST-segment elevation myocardial infarction: an open multicenter randomized trial: the VINO Study.  Eur Heart J. 2002;23(3):230-238
PubMed   |  Link to Article
Fox KA, Poole-Wilson PA, Henderson RA,  et al; Randomized Intervention Trial of Unstable Angina Investigators.  Interventional versus conservative treatment for patients with unstable angina or non–ST-segment elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial.  Lancet. 2002;360:743-751
PubMed   |  Link to Article
Neumann FJ, Kastrati A, Pogatsa-Murray G,  et al.  Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial.  JAMA. 2003;290(12):1593-1599
PubMed   |  Link to Article
van't Hof AW, de Vries ST, Dambrink JH,  et al.  A comparison of two invasive strategies in patients with non ST elevation acute coronary syndromes: results of the early or late intervention in unstable angina (ELISA) pilot study.  Eur Heart J. 2003;24(15):1401-1405
PubMed   |  Link to Article
Mehta SR, Granger CB, Boden WE,  et al; TIMACS Investigators.  Early versus delayed invasive intervention in acute coronary syndromes.  N Engl J Med. 2009;360(21):2165-2175
PubMed   |  Link to Article
Mehta SR, Cannon CP, Fox KA,  et al.  Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.  JAMA. 2005;293(23):2908-2917
PubMed   |  Link to Article
Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.  J Am Coll Cardiol. 2006;48(7):1319-1325
PubMed   |  Link to Article
Bassand JP, Hamm CW, Ardissino D,  et al; Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology.  Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes.  Eur Heart J. 2007;28(13):1598-1660
PubMed   |  Link to Article
Anderson JL, Adams CD, Antman EM,  et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction); American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine.  ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.  Circulation. 2007;116(7):e148-e304
PubMed   |  Link to Article
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.  Lancet. 2003;361(9351):13-20
PubMed   |  Link to Article
Bertrand ME, Simoons ML, Fox KAA,  et al; Task Force on the Management of Acute Coronary Syndromes of the European Society of Cardiology.  Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.  Eur Heart J. 2002;23(23):1809-1840
PubMed   |  Link to Article
Montalescot G, White HD, Gallo R,  et al; STEEPLE Investigators.  Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention.  N Engl J Med. 2006;355(10):1006-1017
PubMed   |  Link to Article
Kastrati A, Mehilli J, Neumann FJ,  et al; Intracoronary Stenting and Antithrombotic: Regimen Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators.  Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial.  JAMA. 2006;295(13):1531-1538
PubMed   |  Link to Article
Giugliano RP, White JA, Bode C,  et al; EARLY ACS Investigators.  Early versus delayed, provisional eptifibatide in acute coronary syndromes.  N Engl J Med. 2009;360(21):2176-2190
PubMed   |  Link to Article
Ferguson JJ, Califf RM, Antman EM,  et al; SYNERGY Trial Investigators.  Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial.  JAMA. 2004;292(1):45-54
PubMed   |  Link to Article
Wiviott SD, Antman EM, Gibson CM,  et al; TRITON-TIMI 38 Investigators.  Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38).  Am Heart J. 2006;152(4):627-635
PubMed   |  Link to Article
Thygesen K, Alpert JS, White HD.Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.  Universal definition of myocardial infarction.  J Am Coll Cardiol. 2007;50(22):2173-2195
PubMed   |  Link to Article
Akkerhuis KM, Alexander JH, Tardiff BE,  et al.  Minor myocardial damage and prognosis: are spontaneous and percutaneous coronary intervention-related events different?  Circulation. 2002;105(5):554-556
PubMed   |  Link to Article
Roe MT, Mahaffey KW, Kilaru R,  et al.  Creatine kinase-MB elevation after percutaneous coronary intervention predicts adverse outcomes in patients with acute coronary syndromes.  Eur Heart J. 2004;25(4):313-321
PubMed   |  Link to Article
Nienhuis MB, Ottervanger JP, Bilo HJG, Dikkeschei BD, Zijlstra F. Prognostic value of troponin after elective percutaneous coronary intervention: a meta-analysis.  Catheter Cardiovasc Interv. 2008;71(3):318-324
PubMed   |  Link to Article
Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials.  Am Heart J. 2009;157(1):132-140
PubMed   |  Link to Article
Beygui F, Montalescot G. Transradial percutaneous coronary intervention for a major reduction of bleeding complications. In: Topol EJ, ed. Textbook of Interventional Cardiology. 5th ed. Philadelphia, PA: Saunders Elsevier; 2008:527-539
Riezebos RK, Ronner E, Ter Bals E,  et al; OPTIMA Trial.  Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes.  Heart. 2009;95(10):807-812
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1. Trial Flow
Graphic Jump Location
Place holder to copy figure label and caption
Figure 2. Peak Troponin I Values (Primary End Point) in Groups Receiving Immediate and Delayed Invasive Intervention
Graphic Jump Location

Curves represent probability density function of the peak troponin value (for each value x of troponin, density is the probability for troponin value to be in the interval [x, x + dx]).

Place holder to copy figure label and caption
Figure 3. Primary End Point (Peak Troponin I Value) in Relevant Subgroups
Graphic Jump Location

Boxes indicate median (interquartile range); whiskers, 10th and 90th deciles. TIMI indicates Thrombolysis in Myocardial Infarction.

Tables

Table Graphic Jump LocationTable 1. Baseline Patient Characteristics
Table Graphic Jump LocationTable 2. Delays and Results of Cardiac Procedures

References

Bhatt DL, Roe MT, Peterson ED,  et al; CRUSADE Investigators.  Utilization of early invasive management strategies for high-risk patients with non–ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.  JAMA. 2004;292(17):2096-2104
PubMed   |  Link to Article
Montalescot G, Dabbous OH, Lim MJ, Flather MD, Mehta RH.Global Registry of Acute Coronary Events Investigators.  Relation of timing of cardiac catheterization to outcomes in patients with non-ST-segment elevation myocardial infarction or unstable angina pectoris enrolled in the Multinational Global Registry of Acute Coronary Events.  Am J Cardiol. 2005;95(12):1397-1403
PubMed   |  Link to Article
Swanson N, Montalescot G, Eagle KA,  et al; GRACE Investigators.  Delay to angiography and outcomes following presentation with high-risk, non-ST-elevation acute coronary syndromes: results from the Global Registry of Acute Coronary Events.  Heart. 2009;95(3):211-215
PubMed   |  Link to Article
Fragmin and Fast Revascularisation During Instability in Coronary Artery Disease Investigators.  Invasive compared with non-invasive treatment in unstable coronary-artery disease: FRISC II prospective randomised multicentre study.  Lancet. 1999;354(9180):708-715
PubMed   |  Link to Article
de Winter RJ, Windhausen F, Cornel JH,  et al; Invasive versus Conservative Treatment in Unstable Coronary Syndromes (ICTUS) Investigators.  Early invasive versus selectively invasive management for acute coronary syndromes.  N Engl J Med. 2005;353(11):1095-1104
PubMed   |  Link to Article
Michalis LK, Stroumbis CS, Pappas K,  et al.  Treatment of refractory unstable angina in geographically isolated areas without cardiac surgery: invasive versus conservative strategy (TRUCS study).  Eur Heart J. 2000;21(23):1954-1959
PubMed   |  Link to Article
Cannon CP, Weintraub WS, Demopoulos LA,  et al; TACTICS (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy)—Thrombolysis in Myocardial Infarction 18 Investigators.  Comparison of early invasive and conservative strategies in patients with unstable coronary syndromes treated with the glycoprotein IIb/IIIa inhibitor tirofiban.  N Engl J Med. 2001;344(25):1879-1887
PubMed   |  Link to Article
Spacek R, Widimsky P, Straka Z,  et al.  Value of first day coronary angiography/angioplasty in evolving non–ST-segment elevation myocardial infarction: an open multicenter randomized trial: the VINO Study.  Eur Heart J. 2002;23(3):230-238
PubMed   |  Link to Article
Fox KA, Poole-Wilson PA, Henderson RA,  et al; Randomized Intervention Trial of Unstable Angina Investigators.  Interventional versus conservative treatment for patients with unstable angina or non–ST-segment elevation myocardial infarction: the British Heart Foundation RITA 3 randomised trial.  Lancet. 2002;360:743-751
PubMed   |  Link to Article
Neumann FJ, Kastrati A, Pogatsa-Murray G,  et al.  Evaluation of prolonged antithrombotic pretreatment (“cooling-off” strategy) before intervention in patients with unstable coronary syndromes: a randomized controlled trial.  JAMA. 2003;290(12):1593-1599
PubMed   |  Link to Article
van't Hof AW, de Vries ST, Dambrink JH,  et al.  A comparison of two invasive strategies in patients with non ST elevation acute coronary syndromes: results of the early or late intervention in unstable angina (ELISA) pilot study.  Eur Heart J. 2003;24(15):1401-1405
PubMed   |  Link to Article
Mehta SR, Granger CB, Boden WE,  et al; TIMACS Investigators.  Early versus delayed invasive intervention in acute coronary syndromes.  N Engl J Med. 2009;360(21):2165-2175
PubMed   |  Link to Article
Mehta SR, Cannon CP, Fox KA,  et al.  Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials.  JAMA. 2005;293(23):2908-2917
PubMed   |  Link to Article
Bavry AA, Kumbhani DJ, Rassi AN, Bhatt DL, Askari AT. Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials.  J Am Coll Cardiol. 2006;48(7):1319-1325
PubMed   |  Link to Article
Bassand JP, Hamm CW, Ardissino D,  et al; Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology.  Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes.  Eur Heart J. 2007;28(13):1598-1660
PubMed   |  Link to Article
Anderson JL, Adams CD, Antman EM,  et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction); American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons; American Association of Cardiovascular and Pulmonary Rehabilitation; Society for Academic Emergency Medicine.  ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction: a Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction): developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine.  Circulation. 2007;116(7):e148-e304
PubMed   |  Link to Article
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials.  Lancet. 2003;361(9351):13-20
PubMed   |  Link to Article
Bertrand ME, Simoons ML, Fox KAA,  et al; Task Force on the Management of Acute Coronary Syndromes of the European Society of Cardiology.  Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation.  Eur Heart J. 2002;23(23):1809-1840
PubMed   |  Link to Article
Montalescot G, White HD, Gallo R,  et al; STEEPLE Investigators.  Enoxaparin versus unfractionated heparin in elective percutaneous coronary intervention.  N Engl J Med. 2006;355(10):1006-1017
PubMed   |  Link to Article
Kastrati A, Mehilli J, Neumann FJ,  et al; Intracoronary Stenting and Antithrombotic: Regimen Rapid Early Action for Coronary Treatment 2 (ISAR-REACT 2) Trial Investigators.  Abciximab in patients with acute coronary syndromes undergoing percutaneous coronary intervention after clopidogrel pretreatment: the ISAR-REACT 2 randomized trial.  JAMA. 2006;295(13):1531-1538
PubMed   |  Link to Article
Giugliano RP, White JA, Bode C,  et al; EARLY ACS Investigators.  Early versus delayed, provisional eptifibatide in acute coronary syndromes.  N Engl J Med. 2009;360(21):2176-2190
PubMed   |  Link to Article
Ferguson JJ, Califf RM, Antman EM,  et al; SYNERGY Trial Investigators.  Enoxaparin vs unfractionated heparin in high-risk patients with non-ST-segment elevation acute coronary syndromes managed with an intended early invasive strategy: primary results of the SYNERGY randomized trial.  JAMA. 2004;292(1):45-54
PubMed   |  Link to Article
Wiviott SD, Antman EM, Gibson CM,  et al; TRITON-TIMI 38 Investigators.  Evaluation of prasugrel compared with clopidogrel in patients with acute coronary syndromes: design and rationale for the TRial to assess Improvement in Therapeutic Outcomes by optimizing platelet InhibitioN with prasugrel Thrombolysis In Myocardial Infarction 38 (TRITON-TIMI 38).  Am Heart J. 2006;152(4):627-635
PubMed   |  Link to Article
Thygesen K, Alpert JS, White HD.Joint ESC/ACCF/AHA/WHF Task Force for the Redefinition of Myocardial Infarction.  Universal definition of myocardial infarction.  J Am Coll Cardiol. 2007;50(22):2173-2195
PubMed   |  Link to Article
Akkerhuis KM, Alexander JH, Tardiff BE,  et al.  Minor myocardial damage and prognosis: are spontaneous and percutaneous coronary intervention-related events different?  Circulation. 2002;105(5):554-556
PubMed   |  Link to Article
Roe MT, Mahaffey KW, Kilaru R,  et al.  Creatine kinase-MB elevation after percutaneous coronary intervention predicts adverse outcomes in patients with acute coronary syndromes.  Eur Heart J. 2004;25(4):313-321
PubMed   |  Link to Article
Nienhuis MB, Ottervanger JP, Bilo HJG, Dikkeschei BD, Zijlstra F. Prognostic value of troponin after elective percutaneous coronary intervention: a meta-analysis.  Catheter Cardiovasc Interv. 2008;71(3):318-324
PubMed   |  Link to Article
Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials.  Am Heart J. 2009;157(1):132-140
PubMed   |  Link to Article
Beygui F, Montalescot G. Transradial percutaneous coronary intervention for a major reduction of bleeding complications. In: Topol EJ, ed. Textbook of Interventional Cardiology. 5th ed. Philadelphia, PA: Saunders Elsevier; 2008:527-539
Riezebos RK, Ronner E, Ter Bals E,  et al; OPTIMA Trial.  Immediate versus deferred coronary angioplasty in non-ST-segment elevation acute coronary syndromes.  Heart. 2009;95(10):807-812
PubMed   |  Link to Article
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