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Management Patterns in Relation to Risk Stratification Among Patients With Non–ST Elevation Acute Coronary Syndromes
Andrew T. Yan, MD;
Raymond T. Yan, MD;
Mary Tan, BSc;
Anthony Fung, MBBS;
Eric A. Cohen, MD;
David H. Fitchett, MD;
Anatoly Langer, MSc, MD;
Shaun G. Goodman, MD, MSc; for the Canadian Acute Coronary Syndromes 1 and 2 Registry Investigators
Arch Intern Med. 2007;167(10):1009-1016.
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.
Author Affiliations: Canadian Heart Research Centre, Terrence Donnelly Heart Centre, and Division of Cardiology, St Michael's Hospital, University of Toronto (Drs A. T. Yan, R. T. Yan, Fitchett, Langer, and Goodman and Ms Tan), and Sunnybrook and Women's College Health Sciences Centre (Dr Cohen), Toronto, Ontario; and Division of Cardiology, Vancouver General Hospital, Vancouver, British Columbia (Dr Fung).
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