PMID- 30522086 OWN - NLM STAT- MEDLINE DCOM- 20191016 LR - 20191016 IS - 1097-6744 (Electronic) IS - 0002-8703 (Linking) VI - 208 DP - 2019 Feb TI - The appropriateness of coronary investigation in myocardial injury and type 2 myocardial infarction (ACT-2): A randomized trial design. PG - 11-20 LID - S0002-8703(18)30293-X [pii] LID - 10.1016/j.ahj.2018.09.016 [doi] AB - BACKGROUND: Elevated troponin level findings among patients presenting with suspected acute coronary syndrome (ACS) or another intercurrent illness undeniably identifies patients at increased risk of mortality. Whilst enhancing our capacity to discriminate risk, the use of high-sensitivity troponin assays frequently identifies patients with myocardial injury (i.e. troponin rise without acute signs of myocardial ischemia) or type 2 myocardial infarction (T2MI; oxygen supply-demand imbalance). This leads to the clinically challenging task of distinguishing type 1 myocardial infarction (T1MI; coronary plaque rupture) from myocardial injury and T2MI in the context of concurrent acute illness. Diagnostic discernment in this context is crucial because MI classification has implications for further investigation and care. Early invasive management is of well-established benefit among patients with T1MI. However, the appropriateness of this investigation in the heterogeneous context of T2MI, where there is high competing mortality risk, remains unknown. Although coronary angiography in T2MI is advocated by some, there is insufficient evidence in existing literature to support this opinion as highlighted by current national guidelines. OBJECTIVE: The objective is to evaluate the clinical and economic impact of early invasive management with coronary angiography in T2MI in terms of all-cause mortality and cost effectiveness. DESIGN: This prospective, pragmatic, multicenter, randomized trial among patients with suspected supply demand ischemia leading to troponin elevation (n=1,800; T2MI [1,500], chronic myocardial injury [300]) compares the impact of invasive angiography (or computed tomography angiography as per local preference) within 5 days of randomization versus conservative management (with or without functional testing at clinician discretion) on all-cause mortality by 2 years. Randomized treatment allocation will be stratified by baseline estimated risk of mortality using the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III risk score. Cost-effectiveness will be evaluated by follow-up on clinical events, quality of life, and resource utilization over 24 months. SUMMARY: Ascertaining the most appropriate first-line investigative strategy for these commonly encountered high-risk T2MI patients in a randomized comparative study will be pivotal in informing evidence-based guidelines that lead to better patient and health care outcomes. CI - Copyright (c) 2018 Elsevier Inc. All rights reserved. FAU - Lambrakis, Kristina AU - Lambrakis K AD - Department of Cardiology, Flinders Medical Centre, Adelaide, Australia. FAU - French, John K AU - French JK AD - School of Medicine, University of New South Wales, Sydney, Australia. FAU - Scott, Ian A AU - Scott IA AD - School of Clinical Medicine, University of Queensland, Brisbane, Australia. FAU - Briffa, Tom AU - Briffa T AD - School of Population and Global Health, University of Western Australia, Perth, Australia. FAU - Brieger, David AU - Brieger D AD - Department of Cardiology, Concord Hospital, Sydney, Australia. FAU - Farkouh, Michael E AU - Farkouh ME AD - Peter Munk Cardiac Centre and the Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Canada. FAU - White, Harvey AU - White H AD - Green Lane Cardiovascular Service, Auckland City Hospital, Auckland, New Zealand. FAU - Chuang, Anthony Ming-Yu AU - Chuang AM AD - Department of Cardiology, Flinders Medical Centre, Adelaide, Australia. FAU - Tiver, Kathryn AU - Tiver K AD - Department of Cardiology, Flinders Medical Centre, Adelaide, Australia. FAU - Quinn, Stephen AU - Quinn S AD - Department of Statistics, Data Science and Epidemiology, Swinburne University of Technology, Melbourne, Australia. FAU - Kaambwa, Billingsley AU - Kaambwa B AD - College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia. FAU - Horsfall, Matthew AU - Horsfall M AD - Department of Cardiology, Flinders Medical Centre, Adelaide, Australia. FAU - Morton, Erin AU - Morton E AD - College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia. FAU - Chew, Derek P AU - Chew DP AD - Department of Cardiology, Flinders Medical Centre, Adelaide, Australia; College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia. Electronic address: derek.chew@flinders.edu.au. LA - eng PT - Journal Article PT - Multicenter Study PT - Pragmatic Clinical Trial PT - Randomized Controlled Trial PT - Research Support, Non-U.S. Gov't DEP - 20181025 PL - United States TA - Am Heart J JT - American heart journal JID - 0370465 RN - 0 (Biomarkers) RN - 0 (Troponin) SB - IM MH - Acute Coronary Syndrome/blood MH - Biomarkers/blood MH - Coronary Angiography/*economics MH - Diagnosis, Differential MH - Heart Injuries/blood/*diagnostic imaging MH - Humans MH - Myocardial Infarction/blood/*diagnostic imaging/etiology/therapy MH - Plaque, Atherosclerotic/*complications MH - Rupture/complications MH - Sample Size MH - Troponin/*blood EDAT- 2018/12/07 06:00 MHDA- 2019/10/17 06:00 CRDT- 2018/12/07 06:00 PHST- 2018/08/17 00:00 [received] PHST- 2018/09/30 00:00 [accepted] PHST- 2018/12/07 06:00 [pubmed] PHST- 2019/10/17 06:00 [medline] PHST- 2018/12/07 06:00 [entrez] AID - S0002-8703(18)30293-X [pii] AID - 10.1016/j.ahj.2018.09.016 [doi] PST - ppublish SO - Am Heart J. 2019 Feb;208:11-20. doi: 10.1016/j.ahj.2018.09.016. Epub 2018 Oct 25.