Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes.
BACKGROUND
Randomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs.


METHODS
We evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality).


RESULTS
Although in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications.


CONCLUSIONS
Despite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management.
Yan
Andrew T
AT
Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada M5B 1W8.
Yan
Raymond T
RT
Tan
Mary
M
Fung
Anthony
A
Cohen
Eric A
EA
Fitchett
David H
DH
Langer
Anatoly
A
Goodman
Shaun G
SG
D000208:Acute Disease; D006328:Cardiac Catheterization; D003327:Coronary Disease / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D003362:Cost-Benefit Analysis; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015337:Multicenter Studies as Topic; D011446:Prospective Studies; D012307:Risk Factors; D013577:Syndrome