Regional Patterns of Use of a Medical Management Strategy for Patients With Non–ST-Segment Elevation Acute Coronary Syndromes Insights From the EARLY ACS Trial

Background—Regional differences in the profile and prognosis of non–ST-segment elevation acute coronary syndrome (NSTE ACS) patients treated with medical management after angiography remain uncertain. Methods and Results—Using data from the Early Glycoprotein IIb/IIIa Inhibition in Non–ST-Segment Elevation Acute Coronary Syndromes (EARLY ACS) trial, we examined regional variations in the use of an in-hospital medical management strategy in NSTE ACS patients who had significant coronary artery disease (CAD) identified during angiography, factors associated with the use of a medical management strategy, and 1-year mortality rates. Of 9406 patients, 8387 (89%) underwent angiography and had significant CAD; thereafter, 1766 (21%) were treated solely with a medical management strategy (range: 18 % to 23 % across 4 major geographic regions). Factors most strongly associated with a medical management strategy were negative baseline troponin values, prior coronary artery bypass grafting, lower baseline hemoglobin values, and greater number of diseased vessels; region was not a significant factor. One-year mortality was higher among patients treated with a medical management strategy compared with those who underwent revascularization (7.8 % versus 3.6%; adjusted hazard ratio, 1.46; 95 % CI, 1.21–1.76), with no significant interaction by region (interaction probability value0.42). Conclusions—Approximately 20 % of NSTE ACS patients with significant CAD in an international trial were treated solely with an in-hospital medical management strategy after early angiography, with no regional differences in factors associated with medical management or the risk of 1-year mortality. These findings have important implications for the conduct of futur