Invasive versus non-invasive management in non-ST segment elevation myocardial infarction patients with pulmonary hypertension

Background Non–ST-segment elevation myocardial infarction (NSTEMI) represents a substantial proportion of acute coronary syndrome and is associated with considerable morbidity and mortality. Pulmonary hypertension (PH) is linked to adverse cardiovascular outcomes and may complicate management decisions in NSTEMI. However, evidence regarding the optimal treatment strategy for NSTEMI patients with PH remains limited. This study evaluated the association between invasive versus conservative management and short- and long-term outcomes in a real-world multicenter cohort. Materials and methods This retrospective multicenter cohort study used data from the Tianjin Health and Medical Big Data Super Platform. Adult patients hospitalized with NSTEMI and concomitant PH between January 2010 and March 2023 were included. Patients were categorized according to treatment strategy during the index hospitalization (invasive vs. conservative management). The primary outcome was 1-year major adverse cardiovascular events (MACE), defined as cardiac death, recurrent myocardial infarction, ischemic stroke, or repeat revascularization. Propensity scores were estimated using logistic regression. The primary analysis used inverse probability of treatment weighting with doubly robust Cox regression models, with additional sensitivity analyses. Results Among 985 patients with NSTEMI and PH, 243 (24.7%) received invasive management and 742 (75.3%) conservative treatment. In doubly robust Cox models, invasive management was associated with a lower risk of 1-year MACE (adjusted hazard ratio [aHR] 0.60, 95% CI 0.41–0.88, P = 0.009) and cardiac death (aHR 0.54, 95% CI 0.34–0.87, P = 0.011). However, bleeding risk was higher in the invasive group (aHR 2.86, 95% CI 1.34–6.11, P = 0.007). Conclusion Invasive management was associated with fewer ischemic events but a higher risk of bleeding in patients with NSTEMI and PH, highlighting the need for individualized treatment strategies.