European Heart Journal (2004) 25, 14941501

Clinical research

Association of revascularisation with low mortality

in non-ST elevation acute coronary syndrome,
a report from GUSTO IV-ACS
J.P. Ottervangera, P. Armstrongb, E.S. Barnathanc, E. Boersmaa, J.S. Cooperc,
E.M. Ohmand, S. Jamese, L. Wallentine, M.L. Simoonsa,*, For the GUSTO
IV-ACS Investigators
a

Erasmus Medical Center, University Hospital Rotterdam, Room H 560, P.O. Box 2040, 3000 CA Rotterdam,
The Netherlands
b
Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
c
Centocor Inc., Malvern, Pennsylvania, USA
d
Duke University Medical Center, Durham, USA
e
Department of Cardiology, Uppsala, Sweden
Received 2 September 2003; revised 28 June 2004; accepted 1 July 2004
Available online 14 August 2004

See page 1471 for the editorial comment on this article (doi:10.1016/j.ehj.2004.05.019)

KEYWORDS

Background Immediate, as well as early, revascularisation is of benefit in patients

with acute coronary syndromes (ACS) presenting with ST elevation. However, trials
comparing invasive versus medical treatment in patients with an acute coronary syndrome without ST elevation do not consistently show improvement in survival after
revascularisation. Accordingly, additional data are warranted.
Methods The effect of revascularisation within 30 days on one-year survival in the
GUSTO IV ACS trial was investigated. A total of 7800 patients were included with an
acute coronary syndrome without ST elevation, documented by either elevated cardiac
troponin or transient or persistent ST-segment depression. In this trial, comparing abciximab versus placebo as initial medical therapy, coronary angiography within 60 h after randomisation was discouraged. In 30-day survivors, those who underwent
revascularisation were compared with 30-day survivors without revascularisation. Adjustments were made for patient characteristics, and for a propensity score that was
adjusted for covariates associated with the likelihood of early revascularisation.
Findings Of the 7496 patients who survived at least 30 days, 2265 (30%) underwent coronary revascularisation within 30 days: 789 patients CABG, 1450 PCI and 26 both CABG
and PCI. Procedure-related mortality was low at 1.8%. Patients with revascularisation
had a lower one-year mortality compared to medically treated patients (2.3% vs. 5.6%,
p < 0.001). After multivariable analyses, patients with revascularisation had a relative
risk of subsequent mortality within 1 year of 0.53 (95% CI 0.370.77) compared to patients without revascularisation.

Non-ST elevation myocardial

infarction;
Acute coronary syndrome;
Revascularisation

* Corresponding author. Tel.: +31 104633938; fax: +31 104635258.

E-mail address: m.simoons@erasmusmc.nl (M.L. Simoons).

0195-668X/$ - see front matter c 2004 Published by Elsevier Ltd on behalf of The European Society of Cardiology.
doi:10.1016/j.ehj.2004.07.004

Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome

1495

Conclusions Revascularisation within 30 days is associated with an improved prognosis in ACS without ST-segment elevation. The relative high mortality in medically
treated patients may be related in part to patient selection, but warrants further
studies to improve outcome of these patients.
c 2004 Published by Elsevier Ltd on behalf of The European Society of Cardiology.

Introduction

Methods

The early prognosis of patients who present with an

acute coronary syndrome (ACS) without ST elevation
is generally good. Nevertheless, 1015% of these
patients develop myocardial infarction or die
within one year after admission.1 Current medical
therapy includes heparin, antiplatelet agents and
anti-ischaemic agents.2 Coronary revascularisation by
either percutaneous coronary intervention (PCI) or
coronary bypass surgery (CABG) is recommended in
patients with recurrent ischaemia or other high-risk
characteristics.
However,
in
clinical
practice
revascularisation is often offered when facilities are
available (local routine).3 There are several
randomised studies addressing the routine use of an
invasive approach in the treatment of non-ST elevation
acute coronary syndromes.410 Although part of the
results support benefit of a systematic invasive
approach, mortality at 612 months follow-up is not
significantly different for revascularisation versus
medical therapy in the majority of these trials
(Table 1).
We investigated the association of revascularisation
and outcome in GUSTO IV-ACS, a large randomised trial
evaluating the GP IIb/IIIa inhibitor abciximab administered during 24 or 48 h in patients with an ACS without
ST-segment elevation.10,11 In this trial, coronary angiography was discouraged within 60 h after randomisation
unless the patient had recurrent or continuing ischaemia
at rest associated with ischaemic ST-T changes that were
unresponsive to intensive medical therapy. Subsequent
revascularisation was at the discretion of the hospital
physician.

Patients, study procedures

Design, methods, and main results of GUSTO IV-ACS have been
described previously.11,12 In short, it was a multi-centre, randomised trial of patients with ACS without persistent ST-segment
elevation. Eligible patients were aged at least 21 years and had
experienced one or more episodes of angina lasting at least 5
min within 24 h before admission. They had either an abnormal
cardiac troponin T or I test or at least 0.5 mm of transient or
persistent ST-segment depression.
Patients were randomly assigned to one of three treatment
groups: abciximab for 24 h (0.25 mg/kg bolus followed by a
0.125 lg/kg per min infusion up to a maximum of 10 lg/min for
24 h) followed by 24 h of placebo infusion; abciximab for 48 h
(same bolus and infusion for total duration of 48 h); or matching
placebo (bolus and 48 h infusion). All patients were to receive
aspirin for at least 30 days if not contraindicated. Furthermore,
all patients received unfractionated heparin as bolus and infusion
for 48 h or low molecular weight heparin (dalteparin) subcutaneously every 12 h for 57 days or until a revascularisation procedure
or discharge. Continuation of anti-thrombin therapy with unfractionated or low molecular weight heparin was left at the discretion
of the investigator. Concomitant therapy with b-blockers was
strongly recommended. Use of all other cardiac medications
(e.g., nitrates, calcium-channel blockers, angiotensin-converting-enzyme inhibitors) was left at the discretion of the investigator. Venous blood samples were collected at baseline and 8, 16,
24, 36 and 48 h after randomisation for assessment of CK-MB. An
elevated troponin was defined as a cardiac troponin T or I above
the upper limit of normal for the local qualitative or quantitative
assay. In addition, quantitative levels of troponin T were also
determined centrally by a third generation assay on an Elecsys
(Roche diagnostics) with the detection limit 0.01 lg/l. Also levels
of C-reactive protein (CRP) were determined at baseline. An
elevated CRP was defined as a CRP value P 10 mg/l.

Table 1 Randomised trials comparing conservative with invasive treatment in acute coronary syndromes without ST elevation
Trial

Year

Total included

Revascularisation (%)

Long-term mortalitya

Invasive

Conservative

Invasive

Conservative

TIMI-IIIB
VANQWISH
FRISC-II
TIMI-18
TRUCS
VINO
RITA 3

1994
1998
1999
2001
2000
2002
2002

1473
920
2457
2220
148
131
1810

60
44
78
61
53
73
44

40
33
37
37
32
39
10

30 (4.1%)
58 (7.8%)
27 (2.2%)
37 (3.3%)
3 (3.9%)
2 (3.1%)
41 (4.6%)

32 (4.4%)
36 (4.9%)
48 (3.9%)
39 (3.5%)
9 (12.5%)
9(13.4%)
36 (3.9)

198 (4.3%)

209 (4.6%)*

Total
a
*

9159

TIMI-IIIB, VANQWISH, FRISC-II, TRUCS, RITA three one-year follow-up, TIMI 18 and VINO 6-months follow-up.
p = 0.6.

1496
The primary endpoint in the trial was the occurrence, within 30
days after randomisation, of death (from any cause) or myocardial
infarction, adjudicated by the Clinical Endpoint Committee.11
Follow-up data were obtained on the vital status up to one year
after randomisation.12 Deaths were reported by the investigator
at each site. Follow-up data were collected via the register office,
the General Practitioner, or via a direct contact with the patient
or his relatives by telephone. Death related to revascularisation
was defined as death within 2 days after the procedure.

Statistical analysis
Patients who underwent revascularisation within 30 days after
enrolment were compared with those not undergoing the procedure. Because patients undergoing revascularisation within 30
days were selected and survived at least until their revascularisation, which may introduce bias, all analyses, including potential beneficial effect of revascularisation, were restricted to
30-day survivors.
Because of the differences in revascularisation rates among
participating hospitals, and the significant differences in baseline
characteristics between patients with and without revascularisation, a propensity score method was applied.13 Firstly, factors
associated with revascularisation were identified. Thereafter, a
multivariable logistic regression analysis was performed to identify independent predictors of revascularisation. On the basis of
the results of the logistic regression analysis, a propensity score
was calculated for each patient. So, the propensity score represents the probability that a patient received revascularisation.
Differences between group means were tested by the two2
tailed Students t test. A v statistic was calculated to test differences between proportions. Survival functions were calculated,
using the KaplanMeier product limit method.14 MantelCox
(or log-rank) test was applied to evaluate the differences
between survival functions.15 Categories for subgroup analyses
include age, gender, diabetes, elevated troponin, ST depression
and CRP status. Four groups were determined that underwent
revascularisation before day 7, at 814 days, at 1521 days, or
between 22 and 30 days after inclusion.
Multivariable Cox proportional-hazards regression analysis
was applied to describe the relation between revascularisation
and one-year survival after adjustment for differences in baseline
characteristics between revascularised and non-revascularised
patients. The follow-up period was divided into different time
periods to assess whether the hazard ratios were constant across
time for the different variables. In the multivariable model, apart
from revascularisation, age, gender and the propensity score, all
baseline variables were included with significant association with
one-year mortality in univariate analysis. To assess whether there
was a U- or J-shape association between continuous variables and
mortality, stratified analyses were performed. The 95% confidence intervals were calculated by standard techniques, using
beta-coefficients and standard errors. Statistical significance
was defined as a p-value of less than 0.05.

Results

J.P. Ottervanger et al.

patients), so the current analyses concerned 7496 patients. Western European hospitals enrolled 3538 (47%)
of these patients, Eastern Europe 2340 (31%), North
America 1059 (14%), and other countries 559 (7%). Local
troponin was available in 6630 patients (88%), with a total of 3864 patients (58%) with positive local troponin.
The central measured quantitative troponin T-levels ranged from 0.01 to 17.3 lg/l and the quartile limits were
0.01, 0.12 and 0.44 lg/l.

Revascularisation
Within 30 days after inclusion, coronary angiography was
performed in 3685 patients (49%). A total of 2265 (30%)
patients underwent revascularisation: 789 patients
CABG, 1450 patients PCI and 26 both CABG and PCI. PCI
was performed after a median of 7 days, whereas CABG
was performed after a median of 12 days. Very few patients (147, 2%) underwent coronary revascularisation
within 48 h, while on study treatment: 1.6% PCI and
0.3% CABG. Differences in baseline characteristics between patients with and without revascularisation within
30 days are summarized in Table 2. Patients with positive
local troponin had revascularisation performed more often and earlier compared to patients with negative local
troponin. Compared to patients with PCI, patients who
underwent CABG were older: 62.4 11.0 vs. 65.1 10.0
years, respectively (p < 0.001).
The proportion of patients undergoing revascularisation within 30 days varied substantially among the different hospitals, from 0% to 100%, with a median of 32%. A
total of 1460 patients (19.5%) were admitted to hospitals
in the highest quartile of revascularisation (50% or more
revascularisation in that specific hospital), whereas 2243
patients (29.9%) were admitted in hospitals in the lowest
quartile of revascularisation (less than 15% revascularisation in that specific hospital). Revascularisation was less
common in Eastern Europe (11.5%) compared to Western
Europe (36.8%) or North America (42.6%).
The likelihood of revascularisation by multivariable
analyses was independently associated with increasing
age, male gender, previous PCI, elevated troponin,
admission in a hospital with a high revascularisation rate,
and no diabetes, no increased CRP, no previous heart
failure and no admission in Eastern Europe. These variables were included in the propensity score of revascularisation. Of the patients with a propensity score in the
lowest quartile, 9.8% had revascularisation within 30
days. Of the patients with a propensity score in the highest quartile, 56% had revascularisation within 30 days.
We assessed the goodness of fit of the propensity score
with the c-statistic (area under the receiver operating
characteristic curve, 0.76) and the HosmerLemeshow
test (p < 0.05).

Baseline characteristics
One-year mortality
Between July 17, 1998 and April 21, 2000 a total of 7800
patients were randomised. Follow-up data up to 365 days
after randomisation were available for 7746 patients
(99.3%). At 30 days follow-up, mortality was 3.9% (304

In the 7496 30-day survivors, after one-year follow-up a

total of 649 patients had died (8.7%). Unadjusted predictors of one-year mortality were assessed. One-year mor-

Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome

1497

Table 2 Differences between patients with and without revascularisation within 30 days in those who survived at least 30 days
Characteristic

With revascularisation (N = 2265)

Without revascularisation (N = 5231)

p-Value

Men
Mean age (years)
Weight at admission (kg)

1645 (73%)
63 (11)
79 (14)

3045 (58%)
66 (11)
77 (14)

<0.001
<0.001
<0.001

History of
MI
Diabetes
Hypertension
Hypercholesterolaemia
PCI
CABG
Stroke
Heart failure
Aspirin use previous 7 days
Eastern Europe
Raised troponina
Raised baseline CK-MB
Mean baseline CK-MB (U/l)
ST-depression
Elevated CRP*
MI within 48 h
Fibrinolytics within 48 h

669 (30%)
440 (19%)
1058 (47%)
745 (33%)
353 (16%)
211 (9%)
43 (2%)
90 (4%)
1915 (85%)
268 (12%)
1265 (56%)
932 (45%)
26.8 47
1772 (78%)
457 (20%)
46 (2.0%)
9 (0.4%)

1595 (31%)
1135 (22%)
2797 (54%)
1479 (28%)
386 (7%)
478 (9%)
138 (3%)
434 (8%)
4356 (83%)
2072 (40%)
2599 (50%)
1836 (38%)
24.9 48
4216 (81%)
1145 (22%)
34 (0.6%)
8 (0.2%)

0.37
0.03
<0.001
<0.001
<0.001
0.8
0.05
<0.001
0.17
<0.001
<0.001
<0.001
0.14
0.02
0.10
<0.001
0.06

a
*

Cardiac troponin T or I above the upper limit of normal for the local qualitative or quantitative assay.
CRP value >10 mg/l.

tality was related to increasing age, diabetes, history of

heart failure, hypertension or previous MI, admission in
Eastern Europe, increased troponin, elevated CRP and a
lower weight. One-year mortality was not associated
with gender, increased cholesterol, previous PCI (before
enrolment in GUSTO IV) or treatment with abciximab.

Mortality and revascularisation

Among the 2340 patients who underwent coronary revascularisation within 30 days, procedure-related mortality,
defined as death within 2 days after revascularisation,
was 1.8%: 1.3% for PCI (19 patients) and 2.6% for CABG
(22 patients, p < 0.001).
In patients who survived at least 30 days, one-year
mortality was lower in those with (2.3%) than those without (5.6%) revascularisation (adjusted survival curves in
Fig. 1, p < 0.001). A similar pattern was apparent in the
analysis of all patients enrolled: 5.5% vs. 9.5% one-year
mortality, respectively (p < 0.001%). The propensity
score for revascularisation was significantly associated
with one-year mortality (p < 0.001), which was 1.1% in
the lowest quartile and 10.1% in the highest quartile.
Multivariable analysis was performed including the propensity score, age, gender and all other variables with
significant association with one-year mortality in univariate analysis. After multivariable analyses in 30-day survivors, mortality remained significantly associated with
lack of revascularisation, increasing age, elevated troponin, elevated CRP, diabetes, previous MI and a history of
heart failure. The propensity score was not significantly
associated with one-year mortality after multivariable
analyses (p = 0.21). Patients with revascularisation had

4
Without Revascularisation
3
P < 0.001
2

With Revascularisation

12
Months after admission

Fig. 1 Adjusted mortality (%) according to medical treatment versus

invasive treatment days in patients who survived at least 30 days.

a relative risk of one-year mortality of 0.53 (95% CI

0.370.77) compared to patients without revascularisation. When the type of revascularisation was entered into
the analysis, survival appeared to be particularly improved after PCI, whereas the results after CABG were
less clear. Patients with PCI had a relative risk of 0.44
(95% CI 0.280.72) for one-year mortality compared to
patients without PCI. Patients with CABG had a relative
risk of 0.83 (95% CI 0.531.33) for one-year mortality
compared to patients without CABG.
In patients who underwent PCI, the timing of the procedure was not associated with one-year mortality. However, in patients after CABG, those who had surgery
within the first week had a higher one-year mortality
(12%) than those operated between day 8 and 30 (6.8%,
p = 0.02).

1498

J.P. Ottervanger et al.

Subgroup analyses
In the patients who survived for 30 days, after univariate
analyses, patients selected to undergo revascularisation
consistently showed improved survival in all subgroups.
The association between revascularisation and one-year
mortality after multivariable analyses in several subgroups is depicted in Fig. 2. In all subgroups a survival
benefit of revascularisation was apparent, although in
younger patients, and in those without ST depression,
this association was not statistically significant.

Abciximab
No significant differences were apparent between patients randomised to placebo, 24 h abciximab or 48 h
abciximab who did, or did not undergo revascularisation.
Also in patients undergoing PCI within 30 days there were
no differences between the three treatment groups.

by PCI improves outcome16 and is the recommended

therapy.17 Furthermore, survival is improved in patients
with myocardial infarction undergoing early revascularisation.18,19 Our analysis provides evidence that in ACS
patients without ST-segment elevation, coronary revascularisation within 30 days after admission is also associated with a favourable one-year survival.
In the Swedish registry of over 21,000 patients surviving 14 days after a first myocardial infarction, one-year
mortality was 4.0% without and 3.3% with revascularisation within 14 days.19 After multivariable analysis,
accounting for baseline characteristics and the propensity for revascularisation, the relative risk was 0.47
(95% CI 0.370.60), which is similar to the relative risk
of 0.53 (0.370.77) in the present study. The similar
benefit of early revascularisation in patients admitted
with or without ST elevation is consistent with the current notion that these represent subsets of the continuous spectrum of acute coronary syndromes.

Registry data and randomised trials

Discussion
In patients hospitalised with an acute coronary syndrome
and ST-segment elevation, immediate revascularisation

Hazard ratio 95% CI

Subgroups

Overall

0.53

0.37-0.77

Sex
Male

0.55

0.35-0.85

Female

0.53

0.28-1.00

Age
< 65 years

0.70

0.36-1.40

> 65 years

0.48

0.31-0.74

Diabetes
Yes

0.51

0.27-0.97

No

0.55

0.35-0.86

ST-depression
Yes

0.47

0.31-0.71

No

0.80

0.36-1.80

Troponin T
Positive

0.54

0.34-0.85

Negative

0.51

0.28-0.94

CRP
Positive

0.57

0.33-0.99

Negative

0.52

0.32-0.85

Prev. MI
Yes

0.60

0.37-0.96

No

0.46

0.26-0.82

0.5

Revascularisation
better

1.0

1.5

2.0
Conservative
better

Fig. 2 Subgroup analysis of one-year mortality, hazard ratio and 95%

confidence days survivors: conservative versus invasive (); multivariable analysis.

Data of registries of the effects of revascularisation in

patients with non-ST elevation myocardial infarction
(non-STEMI) show conflicting results.20,21 For example,
in the OASIS registry, evaluating approximately 8000
patients with suspected non-STEMI from six countries,
a reduction in refractory ischaemia and need for
hospitalisation was observed after revascularisation,
but not a decrease of mortality.22 Randomised trials
comparing an invasive with a conservative approach
show a favouring of invasive treatment,410 without
statistical significance (p = 0.6, Table 1). In FRISC II
and in TACTICS-TIMI 18 a benefit of invasive treatment
was apparent, particularly in patients with positive
troponin.
In GUSTO IV-ACS and the Swedish registry benefits of
early revascularisation appeared much larger than in
the randomized trials, even after adjustment for other
patient and hospital characteristics. It should be appreciated, nevertheless, that such multivariable adjustments
may not correct for all patient characteristics, and do
not fully compensate the effect of careful selection of
patients who are candidates for revascularisation, and
those who are not! Similarly, the results of the randomised trials of invasive versus medical approach should be
interpreted with caution. In these trials, many patients
in the conservative treatment groups crossed-over to
invasive treatment, and many patients allocated to invasive treatment did not undergo such therapy (Table 1).
Thus the true benefit of revascularisation is, most likely,
overestimated by the registries and underestimated by
the trials.

Revascularisation in practice
Recent European and American guidelines for clinical
practice advise an invasive strategy in patients with
ACS and failed medical therapy as well in high risk patients.2,23 This is in agreement with observations from

Association of revascularisation with low mortality in non-ST elevation acute coronary syndrome

FRISC II and TACTICS-TIMI 18 demonstrating that a reduction of death or subsequent myocardial infarction can be
expected only in high-risk groups.6,7,24 In our analyses,
however, survival benefit after revascularisation was
shown in every subgroup, independent of early risk
stratification.

Timing of revascularisation
Patients with non-STEMI have the highest risk of an unfavourable event within the first 48 h after admission.25
Nevertheless, the appropriate timing of coronary angiography and revascularisation remains controversial. In an
early invasive approach, the risk of peri-procedural complications may be increased.26 Therefore, a period of
cooling off has been recommended, in which patients
are medically stabilised. This allows partial resolution
of the initially strong inflammatory response with liberation of cytokines,27 increased generation of free radicals,28 and enhanced activity of the coagulation
system.29 On the other hand, early angiography and subsequent revascularisation may prevent myocardial
infarction or death in a high risk period, whereas prognosis after PCI in these patients has improved with the use
of stents and GP IIb/IIIa inhibitors. Although we found an
increased mortality in patients with early CABG, this can
be due to confounding as very unstable patients will undergo early CABG. In PURSUIT, early PCI (within 24 h) in
patients receiving a GP IIb/IIIa inhibitor had the lowest
event rate after 30 days.30 Possibly, when indicated,
PCI should be performed as soon as possible after admission for ACS while CABG should be deferred. However,
until now, there are few randomised data available
which compared an early with a later invasive approach,
and these give conflicting results.31,32

Angioplasty or surgery
In the randomised trials of invasive versus conservative
management in ACS, there are different findings with regard to mortality after CABG. In FRISC II, the in-hospital
and 30-day mortality after CABG in the invasive group
was, respectively, 1.2% and 2.1%. Similar low rates were
observed in TACTICS TIMI 18, and outcome was comparable between patients undergoing CABG and PCI. In VANQWISH, however, there was a very high mortality in the
CABG group. In recent randomised trials comparing
stented angioplasty and bypass surgery, which included
patients with non-STEMI, the incidence of death or myocardial infarction during follow-up of two years were
similar between the two groups.33,34 The less favourable
outcome after CABG in our study is most likely related to
the selection of patients with more extensive disease to
undergo surgery.

GP IIb/IIIa inhibitors
A number of previous studies have demonstrated beneficial effects of GP IIb/IIIa inhibitors in patients with ACS

1499

without ST-elevation, in particular in patients undergoing PCI.3538 In the guidelines of management of patients
with non-STEMI, use of GP IIb/IIIa inhibitors are recommended, in addition to standard treatment (aspirin and
unfractionated heparin or low molecular weight heparins) for patients with high risk features such as elevated
troponin, ST-segment changes, or recurrent ischaemia.2,39 GP IIb/IIIa inhibitors are particularly effective
in patients with non-STEMI when early PCI is performed.30 GUSTO IV-ACS does not provide additional
information on this issue, as only 128 patients (1.6%)
had PCI within 48 h, while on study medication.

Limitations
We present post hoc analyses, evaluating treatment
strategies that were not randomised. Because coronary
angiography and revascularisation were left at the discretion of the investigator, the decision for angiography
may have introduced both confounding by indication and
confounding by contraindication. Although the complications of coronary angiography are uncommon, several
subgroups may have an increased risk, and patient characteristics may have influenced the decision not to perform angiography.40 It is therefore not surprising that
in GUSTO IV-ACS significant differences could be observed between patients with and without revascularisation (Table 2). Nevertheless, after multivariable analyses
including the known risk factors for impaired outcome,
and a propensity score for revascularisation, a significantly lower one-year mortality was again demonstrated
in patients with revascularisation. A statistical limitation
was that the c-statistic of our propensity score was 0.76,
whereas a c-statistic between 0.8 and 0.9 would have
been more appropriate.
The fact that in the inclusion criteria of GUSTO IV-ACS
coronary angiography was discouraged during or within
12 h after the completion of the study agent infusion,
could have introduced selection bias. Unfortunately, no
detailed information was recorded in the trial about
the findings of angiography. There was also no information about the cause of death, additional revascularisation or re-admissions for other reasons between 30 days
and one year. We had no data on use of medication during follow-up. Particularly in patients who had PCI, more
patients may have used clopidogrel.

Conclusions
Our observations support other reports indicating that in
patients with acute coronary syndromes early revascularisation is associated with a lower mortality.6,7,19,30 However, in most patients with acute coronary syndromes,
early revascularisation was not performed, and the relatively high risk of one-year mortality in these patients remains a concern. This emphasizes the need for studies to
improve management of medically treated patients. Also
the optimal timing of angiography and subsequent

1500

revascularisation if appropriate remains uncertain. We

recommend angiography and revascularisation to be considered during the initial hospitalisation of patients with
an acute coronary syndrome without ST-elevation.

J.P. Ottervanger et al.

17.

18.

Expression of interests
Dr. Barnathan and J.S. Cooper are employees of Centocor Inc. Drs. Armstrong, Wallentin, and Simoons have received grant support from Centocor. In addition, Dr.
Simoons has received grant support from Lilly, and Dr.
Armstrong has received grant support from Zillig.

19.

20.

21.

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