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Perceived risk of ischemic and bleeding events in acute coronary syndromes
Derek P Chew1, Ge Junbo, William Parsonage
1Department of Cardiology, Flinders University, Flinders Medical Centre, Adelaide, SA 5042, Australia. derek.chew@flinders.edu.au
Insights
Physician risk perception in acute coronary syndrome (ACS) is less accurate than objective measures like the GRACE score. Utilizing objective risk stratification tools can improve patient care and outcomes in ACS management.
Area of Science:
- Cardiology
- Clinical Risk Assessment
- Acute Coronary Syndromes
Background:
- Acute coronary syndrome (ACS) registries indicate underutilization of guideline-recommended therapies, particularly in high-risk patients.
- The reasons for this treatment gap, specifically physician risk misperceptions, remain unclear.
Purpose of the Study:
- To compare the accuracy of physician-estimated risk versus objective risk measures for predicting adverse events in acute coronary syndrome (ACS) patients.
- To evaluate the impact of physician risk assessment on treatment decisions and patient outcomes.
Main Methods:
- Prospective registry (PREDICT study) of 1542 ACS patients across 58 hospitals in Australia, China, India, and Russia.
- Clinicians estimated patient risk for ischemic and bleeding events; these estimates were compared with objective risk scores (e.g., GRACE score).
- Statistical analysis using c statistic and integrated discrimination improvement to assess predictive accuracy.
Main Results:
- Physician risk estimates for 6-month death were significantly less accurate (c statistic: 0.652) than the GRACE score (c statistic: 0.812).
- The GRACE score demonstrated superior discrimination for adverse events compared to physician perception alone.
- Invasive management decisions correlated with physician-estimated risk but not with GRACE score-based risk, and higher GRACE scores identified undertreated high-risk patients.
Conclusions:
- Objective risk assessment tools provide superior risk discrimination in ACS compared to subjective physician estimations.
- Further clinical trials are warranted to determine if systematic implementation of objective risk stratification improves patient outcomes in ACS.
Background:
Acute coronary syndrome registries report the use of incomplete guideline therapies, especially among the highest risk patients. Whether this treatment gap results from misperceptions of risk by physicians is uncertain.
Methods And Results:
The Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT) study was a prospective acute coronary syndrome registry in Australia, China, India, and Russia, involving 58 hospitals between May 2009 and February 2011. In-hospital care and events up to 6 months were assessed. At least 2 clinicians involved in patient care estimated the untreated risk and change in risk with each therapy. Physician risk assessment and objective risk measures (eg, Global Registry of Acute Coronary Events [GRACE] score) for death, death/myocardial infarction, and bleeding events were compared using the c statistic and integrated discrimination improvement. In total, 1542 patients and 4230 patient-specific physician estimates were obtained. Of responding clinicians, 81.9% were cardiovascular specialists (years of practice: mean [SD], 11.5 [7.7] years). The median physician-perceived risk of 6-month death was 25% (interquartile range, 14%-35%). The GRACE score was superior to physician estimation (c statistic: GRACE score, 0.812 [95% confidence interval, 0.772-0.851] versus physician, 0.652 [95% confidence interval, 0.596-0.708]; P<0.0001). The GRACE score added to clinician intuition improved discrimination (integrated discrimination improvement, 0.0632 [SE, 0.012]; P<0.0001). Invasive management correlated with physician-estimated risk but not with GRACE risk. Among patients not at high risk by physician estimation, increased risk by GRACE score was associated with higher mortality (3.7% versus 0.8%; P<0.001).
Conclusions:
Objective risk assessment provides superior risk discrimination when compared with physician-estimated risk. Whether systematic use of objective risk stratification improves clinical outcomes should be studied in appropriately designed clinical trials.
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