Management, hospital outcome and revascularization trends in non-ST elevation myocardial infarction with high GRACE
Zohaib Akhter1, Irfan Ali Rind2, Saba Aijaz2
1Department of Clinical Research, Tabba Heart Institute, Karachi, Pakistan.
Insights
High-risk patients with non-ST elevation myocardial infarction (NSTEMI) face increased mortality. Despite this, they are less likely to receive guideline-directed medical therapy and revascularization, indicating potential physician risk aversion.
Area of Science:
- Cardiology
- Clinical Medicine
- Public Health
Background:
- Non-ST elevation myocardial infarction (NSTEMI) is a critical cardiovascular event.
- Risk stratification is essential for managing NSTEMI patients.
- The Global Registry of Acute Coronary Events (GRACE) score helps identify high-risk individuals.
Purpose of the Study:
- To evaluate the clinical characteristics, management, and in-hospital outcomes of high-risk NSTEMI patients.
- To investigate the relationship between GRACE risk score categories and treatment strategies.
- To identify predictors of mortality in this patient cohort.
Main Methods:
- Retrospective cross-sectional study of 817 adult NSTEMI patients with GRACE score >140.
- Data collected from July 2013 to December 2016 at Tabba Heart Institute.
- Patients categorized into GRACE score groups: 140-159, 160-189, and ≥190.
Main Results:
- Men constituted 69.4% of patients, with a mean age of 66.3 years.
- Coronary angiography was performed in 84.4% of patients.
- Higher GRACE scores correlated with less frequent guideline-directed medical therapy, angiography, and revascularization (p<0.05).
- Overall mortality was 7.2%, increasing with higher risk scores (p<0.05).
- Independent predictors of mortality included higher risk score, no revascularization, and lack of guideline-directed medical therapy.
Conclusions:
- Mortality risk escalates with higher GRACE risk scores in NSTEMI patients.
- High-risk NSTEMI patients received guideline-directed medical therapy, angiography, and revascularization less frequently.
- This suggests a potential physician risk aversion in managing high-risk NSTEMI cases.
Objective:
To assess clinical characteristics, management strategies and in-hospital outcome among high-risk patients of non-ST elevation myocardial infarction.
Methods:
The retrospective cross-sectional study was conducted at Tabba Heart Institute, Karachi, and comprised data from July 2013 to December 2016 of adult non-ST elevation myocardial infarction patients who had first cardiac event having Global Registry of Acute Coronary Eventsrisk score>140. Subcategories were formed on the basis of score range 140-159, 160-189 and ?190.Stata 12.1 was used for data analysis.
Results:
Of the 817 patients, 567(69.4%) were men. Overall, mean age was 66.3}9.3 years. Coronary angiography was performed in 692(84.4%). With higher risk score categories, there was less frequent use of guideline directed medical therapy, coronary angiography and percutaneous or surgical revascularisation (p<0.05 each). Overall mortality was 59(7.2%). Mortality rates increased with increase in risk score subcategory (p<0.05). Multivariable model identified higher risk score category, no revascularisation and lack of guideline directed medical therapy as significant independent predictors of mortality (p<0.05 each).
Conclusions:
Mortality increased with higher risk score category. Paradoxically, high-risk patients were less likely to receive guideline directed medical therapy, to undergo coronary angiography and revascularisation, possibly suggesting a risk aversion approach by the treating physicians.
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