Use of clinical risk stratification in non-ST elevation acute coronary syndromes: an analysis from the CONCORDANCE
Rong Bing1, Shaun G Goodman2, Andrew T Yan2
1Department of Cardiology, Concord Hospital, 1A Hospital Road, Concord, Sydney, NSW, Australia.
Insights
Clinical risk stratification (CRS) in non-ST elevation acute coronary syndromes (NSTEACS) is poorly documented and does not align with objective Global Registry of Acute Coronary Events (GRACE) risk scores. This highlights a need for improved risk assessment in NSTEACS patient care.
Area of Science:
- Cardiology
- Clinical Risk Assessment
- Acute Coronary Syndromes
Background:
- Limited data exists on clinical risk stratification (CRS) use versus objective tools in non-ST elevation acute coronary syndromes (NSTEACS).
- Assessing the concordance between CRS and validated risk scores like the Global Registry of Acute Coronary Events (GRACE) score is crucial for patient management.
Purpose of the Study:
- To quantify the utilization of CRS in NSTEACS patients.
- To evaluate the agreement between CRS and GRACE risk scores (GRS).
- To determine the association of CRS with patient outcomes and treatment decisions.
Main Methods:
- Utilized data from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE) registry (n=4512).
- Analyzed predictors of CRS use, CRS-GRS agreement, and compared the predictive accuracy of CRS versus GRS for mortality.
- Examined treatment patterns in relation to CRS-defined risk categories.
Main Results:
- CRS was documented in only 21% of NSTEACS patients, with family history being a positive predictor and ECG changes, biomarkers, dementia, and urban setting being negative predictors.
- A treatment-risk paradox was observed, with higher CRS-risk patients receiving less anticoagulation and angiography.
- CRS showed poor agreement with GRS (kappa=0.034) and was significantly less predictive of in-hospital and 6-month mortality compared to GRS.
Conclusions:
- Clinical risk stratification in Australia does not effectively guide NSTEACS treatment, correlate with established risk scores, or predict outcomes.
- There is a critical need to increase awareness and integrate validated tools like the GRACE score for optimal treatment guidance and improved patient outcomes in NSTEACS.
Aims:
There is little information on clinical risk stratification (CRS) compared to objective risk tools in patients with non-ST elevation acute coronary syndromes (NSTEACS). We quantified CRS use, its agreement with Global Registry of Acute Coronary Events (GRACE) risk scores (GRS), and association with outcomes.
Methods And Results:
Data were extracted from the Australian Cooperative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE), a multi-centre NSTEACS registry. From February 2009 to December 2015, 4512 patients from 41 sites were included. Predictors of CRS use and association with treatment were identified, CRS-GRS agreement determined and prediction of in-hospital and 6-month mortality compared. Clinical risk stratification was documented in 21% of patients. Family history of coronary disease was the only independent predictor of CRS use [odds ratio (OR) 1.23, 95% confidence interval (95% CI) 1.04-1.45]; electrocardiogram changes (OR 0.8, 95% CI 0.68-0.96), elevated biomarkers (OR 0.59, 95% CI 0.48-0.73), dementia (OR 0.56, 95% CI 0.36-0.84), and an urban hospital setting (OR 0.41, 95% CI 0.19-0.89) were independent negative predictors. A treatment-risk paradox was observed: high CRS risk patients received less anticoagulation (79% vs. 88%, P = 0.001) and angiography (83% vs. 71%, P < 0.001). CRS-GRS agreement was poor (kappa coefficient = 0.034) and CRS less predictive for in-hospital (c-statistic 0.54 vs. 0.87, P < 0.001) and 6-month (c-statistic 0.55 vs. 0.74, P < 0.01) mortality.
Conclusion:
In Australia, CRS does not guide treatment, correlate with GRS or predict outcomes. This study suggests the need for greater awareness and integration of validated tools such as the GRACE score to optimally direct treatment and potentially improve outcomes.
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