Analysis of the invasive strategy decision in patients with acute coronary syndrome without ST-segment elevation in a
Maximiliano De Abreu1, Javier A Mariani1, Alejandro Silberstein1
1Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
Insights
Clinical decisions for early invasive strategies in acute coronary syndromes differ from risk scores. A new clinical model better predicts invasive strategy use than the Thrombolysis In Myocardial Infarction Risk Score (TRS).
Area of Science:
- Cardiology
- Clinical Decision-Making
- Acute Coronary Syndromes
Background:
- Observational studies reveal a significant gap between risk scores and invasive strategy use in acute coronary syndromes (ACS).
- Current risk stratification tools may not fully capture the factors influencing early invasive decisions in ACS patients.
Purpose of the Study:
- To delineate the criteria guiding early invasive strategy decisions in non-ST-elevation acute coronary syndrome (NSTE-ACS).
- To compare these clinical decision criteria against the Thrombolysis In Myocardial Infarction Risk Score (TRS).
Main Methods:
- Analysis of 3,187 patients from the Epi-Cardio registry diagnosed with NSTE-ACS.
- Development and validation of a logistic regression model incorporating variables associated with early invasive strategy.
- Evaluation of model performance using receiver operating characteristic (ROC) curves against the TRS.
Main Results:
- Key predictors for early invasive strategy included previous angioplasty, hypercholesterolemia, ST changes, elevated biomarkers, catheterization lab availability, and recurrent angina.
- The clinical decision model demonstrated superior predictive accuracy (ROC area 0.69-0.70) compared to the TRS (ROC area 0.55-0.58).
- Model performance was consistent across derivation and validation cohorts (p < 0.0001).
Conclusions:
- Invasive strategy decisions in ACS are influenced by clinical, evolutionary, and structural variables not fully encompassed by traditional risk scores.
- A comprehensive clinical decision model offers improved prediction of invasive strategy compared to the TRS, potentially explaining risk stratification discrepancies.
Abstract:
Observational studies have reported a marked discrepancy between the risk estimated by scores and the use of an invasive strategy in patients with acute coronary syndromes. The objective is to describe the criteria used to decide an early invasive strategy and to determine the differences between those criteria and the thrombolysis in myocardial infarction risk score (TRS). Patients entered to the Epi-Cardio registry with a diagnosis of non-ST-elevation acute coronary syndrome were analyzed. A logistic regression model including variables associated with an early invasive strategy was developed and validated in 2 consecutive cohorts. The association between the TRS and the clinical decision model with an early invasive strategy was evaluated by receiver operating characteristic (ROC) curves. We included a total of 3,187 patients. In the derivation cohort, variables associated with an early invasive strategy were previous angioplasty (odds ratio [OR] 1.63), hypercholesterolemia (OR 1.36), ST changes (OR 1.49), elevated biomarkers (OR 1.42), catheterization laboratory availability (OR 1.7), recurrent angina (OR 3.45), age (OR 0.98), previous coronary bypass (OR 0.65), previous heart failure (OR 0.40), and heart rate at admission (OR 0.98). The areas under the ROC curves to predict invasive strategy were 0.55 for the TRS and 0.69 for the clinical decision model, p <0.0001. In the validation cohort, ROC areas were 0.58 and 0.70, respectively, p <0.0001. In conclusion, invasive strategy was guided by variables not completely included in risk scores. The clinical, evolutionary, and structural variables included in the model can explain, partially, the discordance existing between risk stratification and medical strategies.
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