title: Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands.
abstract: Cardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS.
  
  
  
  A web-based survey containing clinical vignettes.
  
  
  
  Registered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes 'without' a risk score present, while group 2 completed vignettes 'with' a risk score present.
  
  
  
  129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores.
  
  
  
  When deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.
authors.affiliation: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Josien
authors.initials: J
authors.lastname: Engel
authors.affiliation: Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Judith M
authors.initials: JM
authors.lastname: Poldervaart
authors.affiliation: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Ineke
authors.initials: I
authors.lastname: van der Wulp
authors.affiliation: Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Johannes B
authors.initials: JB
authors.lastname: Reitsma
authors.affiliation: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Martine C
authors.initials: MC
authors.lastname: de Bruijne
authors.affiliation: Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands.
authors.forename: Jeroen J H
authors.initials: JJ
authors.lastname: Bunge
authors.affiliation: Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Maarten J
authors.initials: MJ
authors.lastname: Cramer
authors.affiliation: Department of Cardiology, Alrijne Ziekenhuis, Leiden, The Netherlands.
authors.forename: Wouter J
authors.initials: WJ
authors.lastname: Tietge
authors.affiliation: Department of Cardiology, Deventer Ziekenhuis, Deventer, The Netherlands.
authors.forename: Ruben
authors.initials: R
authors.lastname: Uijlings
authors.affiliation: Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands.|NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000209:etiology; D000072096:Cardiologists / Q000706:statistics & numerical data; D000066491:Clinical Decision-Making; D017023:Coronary Angiography / Q000706:statistics & numerical data*; D004562:Electrocardiography; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D000072658:Non-ST Elevated Myocardial Infarction / Q000000981:diagnostic imaging*; D018579:Patient Selection; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data; D018570:Risk Assessment / Q000379:methods; D014336:Troponin / Q000378:metabolism
chemical_list: D014336:Troponin