Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes
Andrew T Yan1, Raymond T Yan, Mary Tan
1Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada M5B 1W8.
Insights
Despite increased use of cardiac catheterization for non-ST elevation acute coronary syndromes (ACSs), invasive treatments are paradoxically underused in high-risk patients. This treatment-risk paradox limits the full benefits and cost-effectiveness of ACS management.
Area of Science:
- Cardiology
- Acute Coronary Syndromes
- Interventional Cardiology
Background:
- Randomized trials confirm early invasive strategy for high-risk non-ST elevation acute coronary syndromes (ACSs).
- This study examines in-hospital cardiac catheterization and medication use across the spectrum of non-ST elevation ACS risk.
- Investigates the relationship between patient risk stratification and utilization of invasive procedures.
Purpose of the Study:
- To assess trends in cardiac catheterization and medication use for non-ST elevation ACS.
- To identify disparities in invasive management based on patient risk.
- To evaluate the impact of risk stratification on treatment allocation in ACS.
Main Methods:
- Analysis of 4414 patients from the Canadian ACS 1 and ACS 2 Registries (1999-2003).
- Patients categorized into low, intermediate, and high-risk groups using the Global Registry of Acute Coronary Events (GRACE) risk score.
- Statistical analysis to compare rates of cardiac catheterization and medication use across risk groups and over time.
Main Results:
- In-hospital cardiac catheterization use increased significantly from 38.8% to 63.5% between registries.
- Despite increases, cardiac catheterization rates were lower in intermediate (49.7%) and high-risk (49.7%) patients compared to low-risk patients (73.8%) in the ACS 2 Registry.
- An inverse relationship was observed between patient risk and the utilization of revascularization and medications.
Conclusions:
- Temporal increases in invasive procedures for non-ST elevation ACS have not eliminated the treatment-risk paradox.
- Evidence-based invasive and pharmacological therapies are paradoxically underutilized in higher-risk ACS patients.
- Implementation of strategies to address this paradox is crucial for optimizing ACS management and cost-effectiveness.
Background:
Randomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs.
Methods:
We evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality).
Results:
Although in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications.
Conclusions:
Despite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management.
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