Management and outcomes of lower risk patients presenting with acute coronary syndromes in a multinational
G Devlin1, F A Anderson, S Heald
1Waikato Hospital, Hamilton, New Zealand. Devling@waikatodhb.govt.nz
Insights
Risk stratification for acute coronary syndromes (ACS) is suboptimal globally. Despite low in-hospital mortality, recurrent ischemia is common, highlighting the need for improved risk assessment and management strategies for ACS patients.
Area of Science:
- Cardiology
- Clinical Research
- Public Health
Background:
- Acute coronary syndromes (ACS) encompass a spectrum of clinical presentations.
- Risk stratification is crucial for guiding management and improving outcomes in ACS patients.
- Patients presenting without high-risk features require specific evaluation of management patterns and outcomes.
Purpose of the Study:
- To document risk stratification patterns in patients with acute coronary syndromes (ACS) presenting without high-risk features.
- To analyze management practices and patient outcomes in this lower-risk ACS cohort.
- To compare these patterns with those observed in high-risk ACS presentations.
Main Methods:
- Analysis of 11,885 consecutive patients with non-ST segment elevation ACS from the GRACE registry.
- Definition of lower-risk patients: absence of dynamic ST changes, positive troponin, or hemodynamic/arrhythmic instability.
- Comparison of risk stratification (functional testing, angiography, echocardiography) and outcomes between lower-risk and high-risk groups.
Main Results:
- 36% of patients (4252/11,885) were classified as lower risk.
- Risk stratification testing (functional, angiography, echocardiography) was inconsistently applied across both lower and high-risk groups.
- In-hospital death was higher in the high-risk group (2.8% vs 1.0%), but recurrent angina and readmission rates were similar. Six-month rates of death or myocardial infarction were significantly higher in the high-risk group (5.5% vs 2.5%).
Conclusions:
- Risk stratification following ACS presentation is suboptimal globally, irrespective of initial presentation.
- Recurrent ischemia is frequent in both lower and high-risk ACS groups.
- Wider application of risk stratification and tailored management may improve patient outcomes.
Objective:
To document patterns of risk stratification, management practices, and outcomes among patients with acute coronary syndromes (ACS) presenting without high risk features.
Patients:
The study was based on 11,885 consecutive patients presenting with non-ST segment elevation ACS enrolled in GRACE (global registry of acute coronary events). Patients without dynamic ST segment changes, positive troponin (or other cardiac markers), or haemodynamic or arrhythmic instability were defined as being at lower risk.
Main Outcome Measures:
Management and outcomes were compared with high risk presentations.
Results:
Of 11,885 patients presenting with unstable angina or non-ST segment elevation myocardial infarction, 4252 (36%) were regarded as being at lower risk. Functional testing for risk stratification was performed in 1163 of 4207 (28%) lower risk and 1531 of 7521 (20%) high risk patients (p < 0.0001). Coronary angiography was performed in 1930 of 4190 (46%) and 3860 of 7544 (51%), and echocardiography in 1692 of 4190 (40%) and 4348 of 7533 (58%) of lower risk and high risk patients, respectively (p < 0.0001 for both). Over one third of patients did not undergo further risk assessment with angiography or functional testing (2746 of 7437 (37%) high risk, 1499 of 4148 (36%) lower risk, not significant). Death occurring in hospital was more likely in the high risk cohort (41 of 4227 (1.0%) lower risk v 215 of 7586 (2.8%) high risk, p < 0.0001), whereas rates of recurrent angina during admission and readmission were similar in both groups (1354 of 4231 (32%) high risk, 2313 of 7587 (31%) lower risk, not significant). In the six months after discharge, death or myocardial infarction occurred in 79 of 3223 (2.5%) lower risk patients and 302 of 5451 (5.5%) high risk patients (p < 0.0001).
Conclusions:
Globally, further risk stratification after ACS presentation is suboptimal, regardless of presenting characteristics. Although in-hospital death and myocardial infarction are uncommon, recurrent ischaemia is encountered often in both groups. It remains to be seen whether better outcomes may be achieved with wider application of risk stratification and appropriately directed management strategies.
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