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. CONCLUSION: 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.
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. CONCLUSION: 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: K A A Fox; F A Anderson; O H Dabbous; P G Steg; J López-Sendón; F Van de Werf; A Budaj; E P Gurfinkel; S G Goodman; D Brieger Journal: Heart Date: 2006-06-06 Impact factor: 5.994
Authors: Matthew T Roe; Eric D Peterson; L Kristin Newby; Anita Y Chen; Charles V Pollack; Ralph G Brindis; Robert A Harrington; Robert H Christenson; Sidney C Smith; Robert M Califf; Eugene Braunwald; W Brian Gibler; E Magnus Ohman Journal: Am Heart J Date: 2006-06 Impact factor: 4.749
Authors: Robbert J de Winter; Fons Windhausen; Jan Hein Cornel; Peter H J M Dunselman; Charles L Janus; Peter E F Bendermacher; H Rolf Michels; Gerard T Sanders; Jan G P Tijssen; Freek W A Verheugt Journal: N Engl J Med Date: 2005-09-15 Impact factor: 91.245
Authors: Andrew T Yan; Raymond T Yan; Mary Tan; Amparo Casanova; Marino Labinaz; Kumar Sridhar; David H Fitchett; Anatoly Langer; Shaun G Goodman Journal: Eur Heart J Date: 2007-04-16 Impact factor: 29.983
Authors: Finlay A McAlister; Antigone Oreopoulos; Colleen M Norris; Michelle M Graham; Ross T Tsuyuki; Merril Knudtson; William A Ghali Journal: Arch Intern Med Date: 2007-05-28
Authors: Andrew T Yan; Raymond T Yan; Mary Tan; Anthony Fung; Eric A Cohen; David H Fitchett; Anatoly Langer; Shaun G Goodman Journal: Arch Intern Med Date: 2007-05-28
Authors: Jeffrey L Anderson; Cynthia D Adams; Elliott M Antman; Charles R Bridges; Robert M Califf; Donald E Casey; William E Chavey; Francis M Fesmire; Judith S Hochman; Thomas N Levin; A Michael Lincoff; Eric D Peterson; Pierre Theroux; Nanette Kass Wenger; R Scott Wright; Sidney C Smith; Alice K Jacobs; Cynthia D Adams; Jeffrey L Anderson; Elliott M Antman; Jonathan L Halperin; Sharon A Hunt; Harlan M Krumholz; Frederick G Kushner; Bruce W Lytle; Rick Nishimura; Joseph P Ornato; Richard L Page; Barbara Riegel Journal: J Am Coll Cardiol Date: 2007-08-14 Impact factor: 24.094