Use of proven therapies in non-ST-elevation acute coronary syndromes according to evidence-based risk stratification.
BACKGROUND
Current guidelines advise the use of risk stratification to determine which patients should receive more aggressive antithrombotic and invasive therapies. Our objective was to evaluate the relationship between risk stratification and therapeutic decision making in patients with non-ST-segment elevation acute coronary syndromes.


METHODS
We analyzed data from 15,026 patients with acute coronary syndrome who were enrolled into the GRACE registry between 1999 and 2003. We assessed the evidence-based use of antithrombotic therapy and early invasive strategy according to risk profile defined by baseline troponin elevation, presenting ST-segment depression, and GRACE risk score. Patients with possible contraindications were removed to define the use of therapies specifically among clearly eligible patients.


RESULTS
Patients with elevated troponin were more likely to receive enoxaparin (60% vs 50.4%, respectively), GP IIb/IIIa inhibitors (32.8% vs 17.6%), and to undergo catheterization (66% vs 54%) and percutaneous coronary intervention (37.4% vs 25.6%; all P < .0001). Patients with ST depression received modestly more enoxaparin and GP IIb/IIIa than those without ST depression, but not more catheterization (P = .8) or percutaneous coronary intervention (P = .09). Highest risk patients were somewhat less likely to receive enoxaparin (P < .0001) and cardiac catheterization (P = .0002) according to GRACE risk deciles.


CONCLUSIONS
In spite of current guidelines recommending the use of selected therapies in high-risk patients, there is no clear correlation of use of effective therapies with overall risk profile even among eligible patients. Thus, there is substantial opportunity to improve use of effective therapies, especially in high-risk populations.
Oliveira
Gustavo B F
GB
Dante Pazzanese Institute of Cardiology, Sao Paulo, Brazil.
Avezum
Alvaro
A
Anderson
Frederick A
FA
Budaj
Andrzej
A
Dabbous
Omar H
OH
Goodman
Shaun G
SG
Steg
Philippe Gabriel
PG
Goldberg
Robert J
RJ
Brieger
David
D
Fox
Keith A A
KA
Gore
Joel M
JM
Granger
Christopher B
CB
D000208:Acute Disease; D000368:Aged; D000789:Angina, Unstable / Q000188:drug therapy* / Q000601:surgery*; D015906:Angioplasty, Balloon, Coronary; D006328:Cardiac Catheterization; D017984:Enoxaparin / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000601:surgery*; D017410:Practice Guidelines as Topic; D012042:Registries; D018570:Risk Assessment / Q000379:methods; D013577:Syndrome
D017984:Enoxaparin; D005343:Fibrinolytic Agents