VERDICT Studies Optimal Timing of Invasive Angiography and Treatment After Heart Attack

August 28, 2018—The European Society of Cardiology (ESC) announced that findings from the randomized VERDICT trial examining the optimal timing of invasive evaluation after a heart attack were presented at the ESC Congress 2018 held August 25–29 in Munich, Germany.

The trial compared invasive coronary angiography and treatment (if necessary) within 12 hours (very early invasive strategy) versus evaluation and treatment (if necessary) within 48 to 72 hours in high-risk patients with non–ST-segment acute coronary syndrome (NSTE-ACS), including non–ST-segment elevation myocardial infarction (NSTEMI) and unstable angina.

The society noted that ESC guidelines on NSTE-ACS recommend invasive examination and treatment within 2 hours (immediate invasive strategy) in patients at very high risk of death or MI after an initial ACS, within 24 hours in those at high risk (early invasive strategy), and within 72 hours in patients at intermediate risk.

The VERDICT trial enrolled 2,147 patients with NSTEMI or unstable angina (inclusion criteria were either increase in troponin and/or ST-segment/T-wave changes). The patients' average age was 64 years and 66% were men.

Patients were randomized in a 1:1 ratio to very early coronary angiography and possible treatment within 12 hours or deferred coronary angiography and possible treatment within 48 to 72 hours. Patients were followed for at least 18 months for all-cause death, nonfatal MI, hospital admission for refractory ischemia, or hospital admission for heart failure (the primary endpoint).

A total of 1,075 patients were assigned to very early testing, which was performed at a median of 4.7 hours after randomization, whereas the 1,072 patients in the deferred group were examined at a median of 61.6 hours after randomization. Eight in 10 patients had elevated biomarkers, 60% had electrocardiographic changes indicating new ischemia, and approximately 50% had a Global Registry of Acute Coronary Events (GRACE) score > 140 at the time of randomization, all factors that qualify patients as high risk.

During a median follow-up of 4.3 years, the primary endpoint occurred in 27.5% of the very early invasive strategy group versus 29.5% of the deferred group (P = .29). However, in the subgroup of patients with a GRACE score > 140, a very early invasive strategy improved outcome compared to a deferred strategy (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.67–1.00). There was no difference between groups in the rate of complications. There were fewer recurrent MIs in the very early group compared to deferred group (HR, 0.73; 95% CI, 0.56–0.96; P = .025).

Study investigator Professor Thomas Engstrøm, MD, commented in the ESC announcement, "Very early diagnosis and treatment was not superior to the deferred strategy. The results suggest that postponing invasive examination and treatment for up to 72 hours is as good as a very early approach in patients with NSTE-ACS. In line with ESC guidelines, for the subgroup of NSTE-ACS patients with a GRACE score above 140, a very early invasive strategy may be indicated." Prof. Engstrøm is from Copenhagen University Hospital in Copenhagen, Denmark.