Background: Early cardiac catheterization has been shown to improve outcomes in patients with non- ST- elevation acute coronary syndromes but not yet in those with ST- elevation myocardial infarction(STEMI). The benefit of catheterization in both syndromes may depend on patient risk for adverse clinical outcomes. Methods: We analyzed the relation between inhospital catheterization and subsequent clinical outcomes based on risk profile in 8286 patients in the OPUS- TIMI 16 Trial of patients with acute coronary syndromes. Using baseline clinical characteristics, patients were stratified into low- , intermediate- , and high- risk groups. The primary end point was 10- month mortality. The STEMI, non- STEMI(NSTEMI), and unstable angina subgroups were analyzed separately. Results: Inhospital cardiac catheterization was performed in 44% of patients. Mortality rates at 10 months were 1.3% , 2.2% , and 11.3% in the low- , intermediate- , and high- risk groups, respectively. Inhospital cardiac catheterization was associated with a trend to lower mortality among the high- risk patients with STEMI(hazard ratios[HR] 0.57, 95% CI 0.33- 1.01, P=.052) and NSTEMI(HR 0.65, 95% CI 0.39- 1.07, P=.088) but not in those with unstable angina(HR 0.95, 95% CI 0.63- 1.43, P=.82). Catheterization was not associated with any significant difference in mortality in the low- risk or intermediate- risk group. The differences among high- risk patients persisted after adjusting for baseline characteristics; inhospital catheterization was associated with significantly lower mortality in high- risk patients with ST and non- ST myocardial infarction(HR 0.65, 95% CI 0.45- 0.95, P=.03). Conclusions: Inhospital cardiac catheterization is associated with lower mortality in high- risk patients and no difference in mortality in low- risk and intermediate- risk patients after STEMI and NSTEMI. These data support the hypothesis that high- risk patients with either STEMI or NSTEMI may benefit from an early invasive strategy. New prospective randomized trials are warranted, particularly in the STEMI population.
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