Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial

Klaus F Kofoed; Henning Kelbæk; Peter Riis Hansen; Christian Torp-Pedersen; Dan Høfsten; Lene Kløvgaard; Lene Holmvang; Steffen Helqvist; Erik Jørgensen; Søren Galatius; Frants Pedersen; Lia Bang; Kari Saunamaki; Peter Clemmensen; Jesper J Linde; Merete Heitmann; Olav Wendelboe Nielsen; Ilan E Raymond; Ole Peter Kristiansen; Ida Hastrup Svendsen; Jan Bech; Maria Helena Dominguez Vall-Lamora; Charlotte Kragelund; Thomas Fritz Hansen; Jens Dahlgaard Hove; Tem Jørgensen; Gitte G Fornitz; Rolf Steffensen; Birgit Jurlander; Jawdat Abdulla; Stig Lyngbæk; Hanne Elming; Susette Krohn Therkelsen; Ulrik Abildgaard; Jan Skov Jensen; Gunnar Gislason; Lars V Køber; Thomas Engstrøm

doi:10.1161/CIRCULATIONAHA.118.037152

Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial

Klaus F Kofoed, Henning Kelbæk, Peter Riis Hansen, Christian Torp-Pedersen, Dan Høfsten, Lene Kløvgaard, Lene Holmvang, Steffen Helqvist, Erik Jørgensen, Søren Galatius, Frants Pedersen, Lia Bang, Kari Saunamaki, Peter Clemmensen, Jesper J Linde, Merete Heitmann, Olav Wendelboe Nielsen, Ilan E Raymond, Ole Peter Kristiansen, Ida Hastrup SvendsenJan Bech, Maria Helena Dominguez Vall-Lamora, Charlotte Kragelund, Thomas Fritz Hansen, Jens Dahlgaard Hove, Tem Jørgensen, Gitte G Fornitz, Rolf Steffensen, Birgit Jurlander, Jawdat Abdulla, Stig Lyngbæk, Hanne Elming, Susette Krohn Therkelsen, Ulrik Abildgaard, Jan Skov Jensen, Gunnar Gislason, Lars V Køber, Thomas Engstrøm

Department of Clinical Medicine

54 Citations (Scopus)

Abstract

BACKGROUND: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. METHODS: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) (ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. RESULTS: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). CONCLUSIONS: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes.

Original language	English
Journal	Circulation
Volume	138
Issue number	24
Pages (from-to)	2741-2750
Number of pages	10
ISSN	0009-7322
DOIs	https://doi.org/10.1161/CIRCULATIONAHA.118.037152
Publication status	Published - 11 Dec 2018

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Kofoed, K. F., Kelbæk, H., Hansen, P. R., Torp-Pedersen, C., Høfsten, D., Kløvgaard, L., Holmvang, L., Helqvist, S., Jørgensen, E., Galatius, S., Pedersen, F., Bang, L., Saunamaki, K., Clemmensen, P., Linde, J. J., Heitmann, M., Wendelboe Nielsen, O., Raymond, I. E., Kristiansen, O. P., ... Engstrøm, T. (2018). Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial. Circulation, 138(24), 2741-2750. https://doi.org/10.1161/CIRCULATIONAHA.118.037152

Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial. / Kofoed, Klaus F; Kelbæk, Henning; Hansen, Peter Riis et al.
In: Circulation, Vol. 138, No. 24, 11.12.2018, p. 2741-2750.

Research output: Contribution to journal › Journal article › Research › peer-review

Kofoed, KF, Kelbæk, H, Hansen, PR, Torp-Pedersen, C, Høfsten, D, Kløvgaard, L, Holmvang, L, Helqvist, S, Jørgensen, E, Galatius, S, Pedersen, F, Bang, L, Saunamaki, K, Clemmensen, P, Linde, JJ, Heitmann, M , Wendelboe Nielsen, O, Raymond, IE, Kristiansen, OP, Svendsen, IH, Bech, J, Dominguez Vall-Lamora, MH, Kragelund, C, Hansen, TF, Dahlgaard Hove, J, Jørgensen, T, Fornitz, GG, Steffensen, R, Jurlander, B, Abdulla, J, Lyngbæk, S, Elming, H, Therkelsen, SK, Abildgaard, U, Jensen, JS, Gislason, G , Køber, LV & Engstrøm, T 2018, 'Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial', Circulation, vol. 138, no. 24, pp. 2741-2750. https://doi.org/10.1161/CIRCULATIONAHA.118.037152

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title = "Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial",

abstract = "BACKGROUND: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. METHODS: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) (ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. RESULTS: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). CONCLUSIONS: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes.",

author = "Kofoed, {Klaus F} and Henning Kelb{\ae}k and Hansen, {Peter Riis} and Christian Torp-Pedersen and Dan H{\o}fsten and Lene Kl{\o}vgaard and Lene Holmvang and Steffen Helqvist and Erik J{\o}rgensen and S{\o}ren Galatius and Frants Pedersen and Lia Bang and Kari Saunamaki and Peter Clemmensen and Linde, {Jesper J} and Merete Heitmann and {Wendelboe Nielsen}, Olav and Raymond, {Ilan E} and Kristiansen, {Ole Peter} and Svendsen, {Ida Hastrup} and Jan Bech and {Dominguez Vall-Lamora}, {Maria Helena} and Charlotte Kragelund and Hansen, {Thomas Fritz} and {Dahlgaard Hove}, Jens and Tem J{\o}rgensen and Fornitz, {Gitte G} and Rolf Steffensen and Birgit Jurlander and Jawdat Abdulla and Stig Lyngb{\ae}k and Hanne Elming and Therkelsen, {Susette Krohn} and Ulrik Abildgaard and Jensen, {Jan Skov} and Gunnar Gislason and K{\o}ber, {Lars V} and Thomas Engstr{\o}m",

year = "2018",

month = dec,

day = "11",

doi = "10.1161/CIRCULATIONAHA.118.037152",

language = "English",

volume = "138",

pages = "2741--2750",

journal = "Circulation",

issn = "0009-7322",

publisher = "AHA/ASA",

number = "24",

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TY - JOUR

T1 - Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

T2 - VERDICT Randomized Controlled Trial

AU - Kofoed, Klaus F

AU - Kelbæk, Henning

AU - Hansen, Peter Riis

AU - Torp-Pedersen, Christian

AU - Høfsten, Dan

AU - Kløvgaard, Lene

AU - Holmvang, Lene

AU - Helqvist, Steffen

AU - Jørgensen, Erik

AU - Galatius, Søren

AU - Pedersen, Frants

AU - Bang, Lia

AU - Saunamaki, Kari

AU - Clemmensen, Peter

AU - Linde, Jesper J

AU - Heitmann, Merete

AU - Wendelboe Nielsen, Olav

AU - Raymond, Ilan E

AU - Kristiansen, Ole Peter

AU - Svendsen, Ida Hastrup

AU - Bech, Jan

AU - Dominguez Vall-Lamora, Maria Helena

AU - Kragelund, Charlotte

AU - Hansen, Thomas Fritz

AU - Dahlgaard Hove, Jens

AU - Jørgensen, Tem

AU - Fornitz, Gitte G

AU - Steffensen, Rolf

AU - Jurlander, Birgit

AU - Abdulla, Jawdat

AU - Lyngbæk, Stig

AU - Elming, Hanne

AU - Therkelsen, Susette Krohn

AU - Abildgaard, Ulrik

AU - Jensen, Jan Skov

AU - Gislason, Gunnar

AU - Køber, Lars V

AU - Engstrøm, Thomas

PY - 2018/12/11

Y1 - 2018/12/11

N2 - BACKGROUND: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. METHODS: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) (ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. RESULTS: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). CONCLUSIONS: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes.

AB - BACKGROUND: The optimal timing of invasive coronary angiography (ICA) and revascularization in patients with non-ST-segment elevation acute coronary syndrome is not well defined. We tested the hypothesis that a strategy of very early ICA and possible revascularization within 12 hours of diagnosis is superior to an invasive strategy performed within 48 to 72 hours in terms of clinical outcomes. METHODS: Patients admitted with clinical suspicion of non-ST-segment elevation acute coronary syndrome in the Capital Region of Copenhagen, Denmark, were screened for inclusion in the VERDICT trial (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) (ClinicalTrials.gov NCT02061891). Patients with ECG changes indicating new ischemia or elevated troponin, in whom ICA was clinically indicated and deemed logistically feasible within 12 hours, were randomized 1:1 to ICA within 12 hours or standard invasive care within 48 to 72 hours. The primary end point was a combination of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or hospital admission for heart failure. RESULTS: A total of 2147 patients were randomized; 1075 patients allocated to very early invasive evaluation had ICA performed at a median of 4.7 hours after randomization, whereas 1072 patients assigned to standard invasive care had ICA performed 61.6 hours after randomization. Among patients with significant coronary artery disease identified by ICA, coronary revascularization was performed in 88.4% (very early ICA) and 83.1% (standard invasive care). Within a median follow-up time of 4.3 (interquartile range, 4.1-4.4) years, the primary end point occurred in 296 (27.5%) of participants in the very early ICA group and 316 (29.5%) in the standard care group (hazard ratio, 0.92; 95% CI, 0.78-1.08). Among patients with a GRACE risk score (Global Registry of Acute Coronary Events) >140, a very early invasive treatment strategy improved the primary outcome compared with the standard invasive treatment (hazard ratio, 0.81; 95% CI, 0.67-1.01; P value for interaction=0.023). CONCLUSIONS: A strategy of very early invasive coronary evaluation does not improve overall long-term clinical outcome compared with an invasive strategy conducted within 2 to 3 days in patients with non-ST-segment elevation acute coronary syndrome. However, in patients with the highest risk, very early invasive therapy improves long-term outcomes.

U2 - 10.1161/CIRCULATIONAHA.118.037152

DO - 10.1161/CIRCULATIONAHA.118.037152

M3 - Journal article

C2 - 30565996

SN - 0009-7322

VL - 138

SP - 2741

EP - 2750

JO - Circulation

JF - Circulation

IS - 24

ER -

Early Versus Standard Care Invasive Examination and Treatment of Patients With Non-ST-Segment Elevation Acute Coronary Syndrome: VERDICT Randomized Controlled Trial

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