1. Impact of In-Hospital Revascularization on Survival in Patients With Non–ST-Elevation Acute Coronary Syndrome and Congestive Heart Failure Philippe Gabriel Steg, MD; Arthur Kerner, MD; Frans Van de Werf, MD, PhD; José López-Sendón, MD; Joel M. Gore, MD; Gordon FitzGerald, PhD; Laurent J. Feldman, MD, PhD; Frederick A. Anderson, PhD; Álvaro Avezum, MD, PhD; Circulation 2008;118;1163-1171 R3. 조병현

2. Page  2  CHF  Common in patients with an acute coronary syndrome  Reports from the GRACE  Pt with AMI : 20%  Pt with UA : 10%  ACS+CHF  Poor prognosis  Guidelines  High risk NSTE-ACS : early CAG&PCI  GRACE : less likely undergo intervention or medication Background 1. Describe the use of revascularization in patients with NSTE-ACS with and without CHF. 2. Analyze the impact of early revascularization on survival in those with CHF.

3. Page  3  CHF  Killip class I : Includes individuals with no clinical signs of heart failure II : Includes individuals with rales or crackles in the lungs, an S3 gallop, and elevated jugular venous pressure III : Describes individuals with frank acute pulmonary edema IV : Describes individuals in cardiogenic shock or hypotension Background

4. Page  4 Patients Patients enrolled in GRACE >=18 years Clinical history of ACS At least one of followings ECG changes consistent with ACS Increase in cardiac markers Coronary artery disease Method

5. Page  5 Patients Excluded With noncardiovascular causes for the clinical presentation Missing CHF status Cardiogenic shock Transferred from another hospital The revascularization status, date, or other covariates were missing CHF during hospitalization Method

6. Page  6 Method

7. Page  7 RESULTS

8. Page  8 RESULTS

9. Page  9 Result

10. Page  10 RESULTS

11. Page  11 RESULTS

12. Page  12 RESULTS

13. Page  13 RESULTS

14. Page  14 RESULTS

15. Page  15 RESULTS

16. Page  16 RESULTS

17. Page  17 Discussion  If suitable for revascularization –Patients not suitable for procedure due to reasons like comorbidities were excluded  SHOCK trial –Similar result No reduction on overall rate of death at 30days After 6 months, significant survival benefit  Negative interaction with sex –Need for further study regarding the role of revascularization in women with high-risk ACS

18. Page  18 Discussion  Mechanisms for benefit of revascularization –Receive more 2ndary prevention drugs –Reduction in the size of infarction –Salvage of myocardium –Attenuation of remodeling –Prevention of further cardiovascular events

19. Page  19  Strength and limitation –GRACE is largest multinational registry –Include complete spectrum of patients with ACS –Potential biases –The selection of low-risk patients –Due to exclusion of patients who developed heart failure after admission Discussion

20. Page  20 Conclusion  The use of revascularization in NSTE-ACS patients with CHF is low.  It is associated with a significant post-discharge survival benefit.  Broader use of revascularization in these patients may save lives.