Risk stratification in the setting of non-ST elevation acute coronary syndromes 1999-2007
Isuru Ranasinghe1, Bernadette Alprandi-Costa, Vincent Chow
1Concord Repatriation General Hospital, University of Sydney, Australia.
Insights
Clinician risk stratification for acute coronary syndromes has not improved over nine years. Evidence-based therapies are not consistently aligned with patient risk, indicating suboptimal care despite increased treatment uptake.
Area of Science:
- Cardiology
- Clinical Medicine
- Health Services Research
Background:
- Assessing temporal changes in clinician risk stratification for acute coronary syndromes (ACS) is crucial for optimizing patient care.
- Understanding the concordance between patient-assessed risk and evidence-based therapy intensity is key to improving ACS management.
- The Global Registry of Acute Coronary Events (GRACE) provides valuable data for analyzing trends in ACS treatment.
Purpose of the Study:
- To evaluate how clinician risk stratification for non-ST-segment elevation acute coronary syndromes (NSTE-ACS) has evolved over a nine-year period.
- To determine the temporal changes in the alignment between patient risk scores and the utilization of evidence-based therapies in NSTE-ACS.
- To identify if invasive procedures and medications are appropriately targeted based on patient risk stratification.
Main Methods:
- Analysis of 3,562 NSTE-ACS patients from the Australian and New Zealand GRACE registry (1999-2007).
- Patients stratified into risk groups using the GRACE risk score for in-hospital mortality.
- In-hospital use of medications (thienopyridine, heparin, glycoprotein IIb/IIIa inhibitors, aspirin, beta-blockers, statins, ARBs), investigations, and procedures (coronary angiography, PCI) were assessed.
Main Results:
- Invasive management, including coronary angiography and percutaneous coronary intervention (PCI), was consistently higher in low-risk patients than in high-risk patients.
- Rates of angiography and PCI in high-risk patients remained significantly lower than in low-risk patients even in the most recent period (2005-2007).
- Use of most evidence-based medications showed an inverse relationship with patient risk, except for unfractionated heparin, indicating a mismatch between risk and treatment intensity.
Conclusions:
- Despite increased adoption of evidence-based therapies for NSTE-ACS, their application is not consistently guided by objective patient risk stratification.
- Clinician risk assessment and subsequent treatment decisions remain suboptimal, with low-risk patients often receiving more invasive care than high-risk patients.
- There is a persistent gap in aligning therapeutic intensity with patient risk in NSTE-ACS management over the study period.
Abstract:
It is unclear if clinician risk stratification has changed with time. The aim of this study was to assess the temporal change in the concordance between patient presenting risk and the intensity of evidence-based therapies received for non-ST-segment elevation acute coronary syndromes over a 9-year period. Data from 3,562 patients with non-ST-segment elevation acute coronary syndromes enrolled in the Australian and New Zealand population of the Global Registry of Acute Coronary Events (GRACE) from 1999 to 2007 were analyzed. Patients were stratified to risk groups on the basis of the GRACE risk score for in-hospital mortality. Main outcome measures included in-hospital use of widely accepted evidence-based medications, investigations, and procedures. Invasive management was consistently higher in low-risk patients than in intermediate- or high-risk patients (coronary angiography 66.7% vs 63.5% vs 35.3%, p <0.001; percutaneous coronary intervention 31.1% vs 22.0% vs 12.9%, p <0.001). Absolute rates of angiography and percutaneous coronary intervention in the high-risk group remained 24% and 15% lower compared to the low-risk group in the most recent time period (2005 to 2007). In-hospital use of thienopyridine, low-molecular weight heparin, and glycoprotein IIb/IIIa inhibitors showed a similar inverse relation with risk. Prescription of aspirin, β blockers, statins, and angiotensin receptor blockers was inversely related to risk before 2004, although this inverse relation was no longer present in the most recent time period (2005 to 2007). Only in-hospital use of unfractionated heparin showed use concordant with patient risk status. In conclusion, despite an overall increase in the uptake of evidence-based therapies, most investigations and treatments are not targeted on the basis of patient risk. Clinician risk stratification remains suboptimal compared to objective measures of patient risk.
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