title: Temporal trends in the use of invasive cardiac procedures for non-ST segment elevation acute coronary syndromes according to initial risk stratification.
abstract: BACKGROUND
  Current guidelines support an early invasive strategy in the management of high-risk non-ST elevation acute coronary syndromes (NSTE-ACS). Although studies in the 1990s suggested that highrisk patients received less aggressive treatment, there are limited data on the contemporary management patterns of NSTE-ACS in Canada.
  
  
  OBJECTIVE
  To examine the in-hospital use of coronary angiography and revascularization in relation to risk among less selected patients with NSTE-ACS.
  
  
  METHODS
  Data from the prospective, multicentre Global Registry of Acute Coronary Events (main GRACE and expanded GRACE2) were used. Between June 1999 and September 2007, 7131 patients from across Canada with a final diagnosis of NSTE-ACS were included the study. The study population was stratified into low-, intermediate- and high-risk groups, based on their calculated GRACE risk score (a validated predictor of in-hospital mortality) and according to time of enrollment.
  
  
  RESULTS
  While rates of in-hospital death and reinfarction were significantly (P<0.001) greater in higher-risk patients, the in-hospital use of cardiac catheterization in low- (64.7%), intermediate- (60.3%) and highrisk (42.3%) patients showed an inverse relationship (P<0.001). This trend persisted despite the increase in the overall rates of cardiac catheterization over time (47.9% in 1999 to 2003 versus 51.6% in 2004 to 2005 versus 63.8% in 2006 to 2007; P<0.001). After adjusting for confounders, intermediate-risk (adjusted OR 0.80 [95% CI 0.70 to 0.92], P=0.002) and high-risk (adjusted OR 0.38 [95% CI 0.29 to 0.48], P<0.001) patients remained less likely to undergo in-hospital cardiac catheterization.
  
  
  CONCLUSIONS
  Despite the temporal increase in the use of invasive cardiac procedures, they remain paradoxically targeted toward low-risk patients with NSTE-ACS in contemporary practice. This treatment-risk paradox needs to be further addressed to maximize the benefits of invasive therapies in Canada.
authors.affiliation: Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, USA.
authors.forename: S
authors.initials: S
authors.lastname: Jedrzkiewicz
authors.forename: S G
authors.initials: SG
authors.lastname: Goodman
authors.forename: R T
authors.initials: RT
authors.lastname: Yan
authors.forename: R C
authors.initials: RC
authors.lastname: Welsh
authors.forename: J
authors.initials: J
authors.lastname: Kornder
authors.forename: J Paul
authors.initials: JP
authors.lastname: DeYoung
authors.forename: G C
authors.initials: GC
authors.lastname: Wong
authors.forename: B
authors.initials: B
authors.lastname: Rose
authors.forename: F R
authors.initials: FR
authors.lastname: Grondin
authors.forename: R
authors.initials: R
authors.lastname: Gallo
authors.forename: W
authors.initials: W
authors.lastname: Huang
authors.forename: J M
authors.initials: JM
authors.lastname: Gore
authors.forename: A T
authors.initials: AT
authors.lastname: Yan
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy*; D000367:Age Factors; D000368:Aged; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data / Q000639:trends; D002170:Canada; D006328:Cardiac Catheterization / Q000379:methods / Q000706:statistics & numerical data; D015331:Cohort Studies; D017023:Coronary Angiography / Q000706:statistics & numerical data / Q000639:trends; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data / Q000639:trends; D003657:Decision Making; D004562:Electrocardiography; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization / Q000706:statistics & numerical data* / Q000639:trends; D016017:Odds Ratio; D017410:Practice Guidelines as Topic; D011336:Probability; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012308:Risk Management; D012720:Severity of Illness Index; D012737:Sex Factors; D016019:Survival Analysis