g., young diabetics with elevated troponin levels). Timing

of Invasive Strategy The large-scale multicenter TIMACS trial15 compared early (≤24 hours of randomization, median 14 hours) vs. delayed (≥36 hours, median 50 hours) angiography and intervention in patients with non–ST-segment elevation ACS. The study was terminated prematurely because of recruitment challenges (N = 3,031), and showed a nonsignificant difference in the incidence of the primary composite outcome of death, MI, or stroke (early vs. delayed; 9.6% vs. 11.3%, P = 0.15). However, early intervention reduced the secondary endpoint of death, MI, or refractory Inhibitors,research,lifescience,medical ischemia Inhibitors,research,lifescience,medical (12.9% vs. 9.5%; HR: 0.72; 95% CI: 0.58–0.89), which was driven by lower incidence of refractory ischemia.13 In addition, patients in the highest-risk subgroup (GRACE risk score >140) experienced a 35% significant risk reduction in the incidence of the primary ischemic endpoint (21.0% vs. 13.9%, P = 0.006).13 Inhibitors,research,lifescience,medical On the other hand, the ABOARD study16 failed to show that a more aggressive strategy of very early intervention for non-ST-elevation ACS (analogous to the standard of primary PCI for STEMI) would lead to improved outcomes. Based on the aforementioned findings, the 2012 UA/NSTEMI guideline update

recommended early invasive strategy (within 12–24 hours)

as a reasonable strategy for initially stabilized high-risk UA/NSTEMI patients.1 Revascularization in ACS Patients with Chronic Kidney Disease The SWEDEHEART study17 included a cohort of 23,262 consecutive patients hospitalized for NSTEMI in Sweden between Inhibitors,research,lifescience,medical 2003 and 2006. The study Autophagy Compound Library demonstrated that early revascularization within 14 days was associated with an improved 1-year mortality. After adjustment, the 1-year mortality in the overall cohort Inhibitors,research,lifescience,medical was 36% lower in NSTEMI patients who underwent early revascularization (HR: 0.64; 95% CI: 0.56–0.73; P <0.001). ADP ribosylation factor The improvement in 1-year mortality was similar in patients with normal estimated glomerular filtration rate and in those with mild and moderate chronic kidney disease (CKD).17 There was no benefit observed in the subgroups of patients with stages 4 and 5 CKD; however, the latter subgroups included fewer patients and the study was underpowered to detect differences in these patients. Despite the contemporary SWEDEHEART registry limitations, including nonrandomized data and the potential for selection bias, the 2012 UA/NSTEMI guideline update recommended an early invasive strategy (i.e., diagnostic angiography with intent to perform revascularization) as a reasonable strategy in patients with mild and moderate CKD.