title: Analysis of the invasive strategy decision in patients with acute coronary syndrome without ST-segment elevation in a real-world setting.
abstract: Observational studies have reported a marked discrepancy between the risk estimated by scores and the use of an invasive strategy in patients with acute coronary syndromes. The objective is to describe the criteria used to decide an early invasive strategy and to determine the differences between those criteria and the thrombolysis in myocardial infarction risk score (TRS). Patients entered to the Epi-Cardio registry with a diagnosis of non-ST-elevation acute coronary syndrome were analyzed. A logistic regression model including variables associated with an early invasive strategy was developed and validated in 2 consecutive cohorts. The association between the TRS and the clinical decision model with an early invasive strategy was evaluated by receiver operating characteristic (ROC) curves. We included a total of 3,187 patients. In the derivation cohort, variables associated with an early invasive strategy were previous angioplasty (odds ratio [OR] 1.63), hypercholesterolemia (OR 1.36), ST changes (OR 1.49), elevated biomarkers (OR 1.42), catheterization laboratory availability (OR 1.7), recurrent angina (OR 3.45), age (OR 0.98), previous coronary bypass (OR 0.65), previous heart failure (OR 0.40), and heart rate at admission (OR 0.98). The areas under the ROC curves to predict invasive strategy were 0.55 for the TRS and 0.69 for the clinical decision model, p <0.0001. In the validation cohort, ROC areas were 0.58 and 0.70, respectively, p <0.0001. In conclusion, invasive strategy was guided by variables not completely included in risk scores. The clinical, evolutionary, and structural variables included in the model can explain, partially, the discordance existing between risk stratification and medical strategies.
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina. Electronic address: maxideabreu@gmail.com.
authors.forename: Maximiliano
authors.initials: M
authors.lastname: De Abreu
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Javier A
authors.initials: JA
authors.lastname: Mariani
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Alejandro
authors.initials: A
authors.lastname: Silberstein
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Cristian
authors.initials: C
authors.lastname: Guridi
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Hecht
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Juan A
authors.initials: JA
authors.lastname: Gagliardi
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Hernán C
authors.initials: HC
authors.lastname: Doval
authors.affiliation: Grupo de Estudio, Docencia e Investigación Clínica, Investigadores del Registro Epi-Cardio, Buenos Aires, Argentina.
authors.forename: Carlos D
authors.initials: CD
authors.lastname: Tajer
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy*; D000368:Aged; D001118:Argentina; D002423:Cause of Death; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods; D001026:Coronary Artery Bypass / Q000379:methods / Q000401:mortality; D003657:Decision Making; D004562:Electrocardiography; D005260:Female; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D012042:Registries; D015203:Reproducibility of Results; D018570:Risk Assessment; D012720:Severity of Illness Index; D016019:Survival Analysis; D015912:Thrombolytic Therapy / Q000379:methods* / Q000401:mortality; D016896:Treatment Outcome