Acute Versus Subacute Angioplasty in Patients With NON-ST-Elevation Myocardial Infarction (NONSTEMI)

Acute Versus Subacute Angioplasty in Patients With NON-ST-Elevation Myocardial Infarction (NON-ST-Elevation Myocardial Infarction=NONSTEMI Trial)

Patients with acute myocardial infarction (AMI) are categorized according to the electrocardiogram (ECG) findings into: 1) patients with ST-Elevation Myocardial Infarction (STEMI), 2) patients with Bundle Branch Block Myocardial Infarction (BBBMI), and 3) remaining patients with so-called NON-ST-Elevation Myocardial Infarction (NONSTEMI). Patients with STEMI or BBBMI are treated with acute angioplasty (PPCI=primary percutaneous coronary intervention), and the sooner PPCI is performed the lower is the mortality. This is why prehospital diagnosis and field-triage of patients with STEMI directly to heart centers with PPCI facilities is recommended. In patients with NONSTEMI previous trials have indicated that early angioplasty, within 72 hours of symptom onset, is associated with improved outcome when compared to late angioplasty or conservative therapy. No trials have so far been able to diagnose patients with NONSTEMI in the prehospital phase or immediately on arrival at a hospital, and triage them directly to PPCI. Implementation of point-of-care (POC) testing of biomarkers may enable prehospital or early inhospital establishment of the diagnosis NONSTEMI. The aim of the present trial is to identify patients with NONSTEMI in the prehospital phase or immediately on arrival at the local hospital based on a) symptoms, b) POC testing and c) ECG findings and then randomize patients to I) PPCI, or II) medical therapy and angiography/angioplasty within 72 hours (todays routine). Se below for detailed description

In the present trial patients with a) typical angina pectoris (AP) combined with b1) rise in biomarkers on POC testing (prehospital/immediately inhospital) and/or b2) ST-segment depression of more than 0.2 mV in two contiguous leads or more than 0.1 mV in four contiguous leads are randomized to I) PPCI (same protocol as in STEMI patients) or II) medical therapy and angiography/angioplasty within 72 hours (todays routine practice). The primary purposes of the present trial is threefold: To evaluate if it is possible to diagnose patients with NONSTEMI in the prehospital phase or immediately on arrival at the hospital (N=250 patients) To compare a combined endpoint of mortality, re-infarction (during index admission or readmitted), or readmission with Congestive Heart Failure (CHF) between group I (PPCI strategy) and group II (routine strategy) (N=2500 patients). To compare mortality between group I and II (N=4500 patients). Secondary purposes of the present trial is: To evaluate whether there is difference in the primary endpoints in patients randomized within or after 12 hours of symptom onset. To evaluate whether there is difference in the primary endpoints in patients randomized in the prehospital phase and on admission to the hospital, respectively. To evaluate whether there is difference in the primary endpoints in patients with a final diagnosis of AMI, as adjudicated by a clinical event committee. To evaluate whether there is difference in the primary endpoints in patients with or without diabetes, respectively. To compare a combined endpoint of mortality, readmission with AMI, readmission with CHF, readmission with AP, revascularization (not planned on index admission). To compare a combined safety endpoint of stroke or serious bleeding between group I and II. To evaluate if there is difference in the frequency of PCI and CABG in group I versus II. To compare total admission time between group I and II. To compare total cost between group I and II. To compare total duration where the patient is on sick leave between group I and II

Acute Coronary Syndrome, Myocardial infarction, Angioplasty, Prehospital emergency care, Biological markers, Troponin, Point-of-Care systems

Patients are treated with Aspirin, ADP-blocker and heparin and field-triaged or transferred immediately to an invasive center for PPCI

Patients are treated as today: Admission to local hospital, Low-molecular-weight heparin (LMWH), Aspirin, ADP-blocker and within 72 hours transfer for angiography/angioplasty. Patients with a Grace score > 140 will be transferred for angiography/angioplasty within 24 hours. Patients with refractory angina, severe heart failure, life-threatening ventricular arrhythmias or haemodynamic instability will be transferred acutely for angiography/angioplasty according to the european guidelines.

Patients are treated with Aspirin, ADP-blocker and heparin and field-triaged or transferred immediately to an invasive center for PPCI

Re-infarction (during index admission or readmitted) adjudicated by and endpoint committee. The endpoint committee is blinded to the initial randomization. The "Universal definition of Myocadial infarction" will be used to classify reinfarction. Biomarkers will be recorded with emphasis on the need of obtaining blood samples until a peak has been reached during index hospitaltization before reinfarction can be considered. Re-infarction will require a 20% relative rise in biomarker level.

Readmission or visit in the outpatient clinic with CHF. Readmission or visit with CHF needs to be adjudicated by an endpoint committee blinded to the initial randomization.

An endpoint committee needs to evaluate whether each patient had AMI on the index admission. This evaluation is performed without the endpoint committee being aware whether the patient was randomized to PPCI or conventional therapy. The endpoint committee will classify whether the patient had: a) NONSTEMI, b) STEMI with symptom duration <=12 hours, c) STEMI with symptom duration >12 hours, d) BBBMI with symptom duration <=12 hours or e) BBBMI with symptom duration > 12 hours.

The national health registry is used to determine whether the patient is readmitted with AP. Time from index admission to first readmission with AP is determined. The endpoint committee adjudicate readmissions with AP blinded to original treatment strategy (Group I versus II)

The national health registry used to determine whether the patient is readmitted with stroke. Stroke was defined as focal loss of neurologic function caused by an ischemic or hemorrhagic event, with residual symptoms lasting at least 24 hours or leading to death. Time from index admission to first readmission with stroke is determined. The endpoint committee adjudicate readmissions with stroke blinded to original treatment strategy (Group I versus II).

The national health registry is used to determine whether the patient has non-scheduled re-intervention performed (re-intervention not scheduled at index admission). Time from index admission to first re-intervention and type of re-interverntion (PCI or CABG) is determined. The endpoint committee adjudicate re-interventions blinded to original treatment strategy (Group I versus II)

The national health registry is used to determine number of days the patietns was admitted during index hospitalization (local hospital and interventional hospital).

The national DREAM database is used to determined whether the patient is on sick leave from work after index hospitalization and the duration of sick leave from work.

The total cost for each treatment strategy is calculated: EMS-transport, admission, cost for PCI / CABG.

The national health registry is used to determine bleeding events. The same criteria for bleeding classification is used as in the PLATO trial (see NEJM 2009 for details) to categorize: 1) Major life-threatening bleeding, 2) Other major bleeding. In addition BARC type 4 (CABG-related) bleedings are registered.

Time from ambulance call to PCI or CABG is performed or angiography is performed without indication for PCI or CABG

Inclusion Criteria: Angina Elevated biomarkers (Point-of-care testing) either prehospital or immediately on admission ST-segment depression of 0.2mV or more in two contiguous leads or 0.1 mV or more in four contiguous leads. Patient can be randomized either in the prehospital phase or within 30 minutes of admission to a hospital Exclusion Criteria: Tachycardia > 120 Age < 18 or > 80 years Indication for PPCI already fulfilled Dementia Patient cannot understand the study information Presumed "troponisme" Left ventricular hypertrophy Known dialysis Previous CABG Pregnancy

Rasmussen MB, Stengaard C, Sorensen JT, Riddervold IS, Sondergaard HM, Niemann T, Dodt KK, Frost L, Jensen T, Raungaard B, Hansen TM, Giebner M, Rasmussen CH, Botker HE, Kristensen SD, Maeng M, Christiansen EH, Terkelsen CJ. Comparison of Acute Versus Subacute Coronary Angiography in Patients With NON-ST-Elevation Myocardial Infarction (from the NONSTEMI Trial). Am J Cardiol. 2019 Sep 15;124(6):825-832. doi: 10.1016/j.amjcard.2019.06.007. Epub 2019 Jun 24.