ACUTE CORONARY SYNDROMES

¹ Cardiovascular Research, Division of Medical & Radiological Sciences, The University of Edinburgh, Edinburgh, UK
² Center for Outcomes Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
³ Cardiology, Hôpital Bichat, Paris, France
⁴ Department of Cardiology, Hospital Universitario La Paz, Madrid, Spain
⁵ Department of Cardiology, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium
⁶ Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland
⁷ Department of Cardiology, ICYCC Favaloro Foundation, Buenos Aires, Argentina
⁸ Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
⁹ Coronary Care Unit, Concord Hospital, Sydney, Australia

Correspondence to:
Correspondence to:
Professor Keith A A Fox
Cardiovascular Research, University of Edinburgh, Chancellor’s Building, 49 Little France Crescent, Edinburgh EH16 4SB, UK; k.a.a.fox{at}ed.ac.uk

Objective: To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies.

Methods: GRACE (Global Registry of Acute Coronary Events) is a multinational, observational cohort study. This study involved 24 189 patients enrolled at 73 hospitals with on-site angiographic facilities.

Results: Overall, 32.5% of patients with a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (CABG; 4.0% in STEMI). The cumulative rate of in-hospital death rose correspondingly with the GRACE risk score (variables: age, Killip class, systolic blood pressure, ST segment deviation, cardiac arrest at admission, serum creatinine, raised cardiac markers, heart rate), from 1.2% in low-risk to 3.3% in medium-risk and 13.0% in high-risk patients (c statistic = 0.83). PCI procedures were more likely to be performed in low- (40% non-STEMI, 60% STEMI) than medium- (35%, 54%) or high-risk patients (25%, 41%). No such gradient was apparent for patients undergoing CABG. These findings were seen in STEMI and non-ST elevation ACS, in all geographical regions and irrespective of whether hospitals adopted low (4.2–33.7%, n = 7210 observations), medium (35.7–51.4%, n = 7913 observations) or high rates (52.6–77.0%, n = 8942 observations) of intervention.

Conclusions: A risk-averse strategy to angiography appears to be widely adopted. Proceeding to PCI relates to referral practice and angiographic findings rather than the patient’s risk status. Systematic and accurate risk stratification may allow higher-risk patients to be selected for revascularisation procedures, in contrast to current international practice.

Abbreviations: CABG, coronary artery bypass grafting; GRACE, Global Registry of Acute Coronary Events; ICTUS, Invasive versus Conservative Treatment in Unstable Coronary Syndromes; NSTEMI, non-ST segment elevation myocardial infarction; PCI, percutaneous coronary intervention; STEMI, ST segment elevation myocardial infarction

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Article

WEB TOP 10
Heart 2007 93: 655. [Extract] [Full Text] [PDF]

This article has been cited by other articles:

• Gale, C. P, Simms, A. D, Cattle, B. A, Greenwood, D., West, R. M (2009). Point of care testing in acute coronary syndromes: when and how?. Heart 95: 1128-1129 [Full Text]  
• Kurz, D J, Bernstein, A, Hunt, K, Radovanovic, D, Erne, P, Siudak, Z, Bertel, O (2009). Simple point-of-care risk stratification in acute coronary syndromes: the AMIS model. Heart 95: 662-668 [Abstract] [Full Text]  
• Yan, A. T., Yan, R. T., Huynh, T., Casanova, A., Raimondo, F. E., Fitchett, D. H., Langer, A., Goodman, S. G., for the Canadian Acute Coronary Syndrome Registry, (2009). Understanding Physicians' Risk Stratification of Acute Coronary Syndromes: Insights From the Canadian ACS 2 Registry. Arch Intern Med 169: 372-378 [Abstract] [Full Text]  
• Lim, H. S., Farouque, O., Andrianopoulos, N., Yan, B. P., Lim, C. C.S., Brennan, A. L., Reid, C. M., Freeman, M., Charter, K., Black, A., New, G., Ajani, A. E., Duffy, S. J., Clark, D. J., on behalf of the Melbourne Interventional Group, (2009). Survival of Elderly Patients Undergoing Percutaneous Coronary Intervention for Acute Myocardial Infarction Complicated by Cardiogenic Shock. J Am Coll Cardiol Intv 2: 146-152 [Abstract] [Full Text]  
• Swanson, N, Montalescot, G, Eagle, K A, Goodman, S G, Huang, W, Brieger, D, Devlin, G, for the GRACE Investigators, (2009). Delay to angiography and outcomes following presentation with high-risk, non-ST-elevation acute coronary syndromes: results from the Global Registry of Acute Coronary Events. Heart 95: 211-215 [Abstract] [Full Text]  
• Medi, C., Montalescot, G., Budaj, A., Fox, K. A.A., Lopez-Sendon, J., FitzGerald, G., Brieger, D. B., on behalf of the GRACE Investigators, (2009). Reperfusion in Patients With Renal Dysfunction After Presentation With ST-Segment Elevation or Left Bundle Branch Block: GRACE (Global Registry of Acute Coronary Events). J Am Coll Cardiol Intv 2: 26-33 [Abstract] [Full Text]  
• Authors/Task Force Members, , Van de Werf, F., Bax, J., Betriu, A., Blomstrom-Lundqvist, C., Crea, F., Falk, V., Filippatos, G., Fox, K., Huber, K., Kastrati, A., Rosengren, A., Steg, P. G., Tubaro, M., Verheugt, F., Weidinger, F., Weis, M., ESC Committee for Practice Guidelines (CPG), , Vahanian, A., Camm, J., De Caterina, R., Dean, V., Dickstein, K., Filippatos, G., Funck-Brentano, C., Hellemans, I., Kristensen, S. D., McGregor, K., Sechtem, U., Silber, S., Tendera, M., Widimsky, P., Zamorano, J. L., Document Reviewers, , Silber, S., Aguirre, F. V., Al-Attar, N., Alegria, E., Andreotti, F., Benzer, W., Breithardt, O., Danchin, N., Mario, C. D., Dudek, D., Gulba, D., Halvorsen, S., Kaufmann, P., Kornowski, R., Lip, G. Y. H., Rutten, F. (2008). Management of acute myocardial infarction in patients presenting with persistent ST-segment elevation: The Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology:. Eur Heart J 29: 2909-2945 [Full Text]  
• Adabag, A. S., Therneau, T. M., Gersh, B. J., Weston, S. A., Roger, V. L. (2008). Sudden Death After Myocardial Infarction. JAMA 300: 2022-2029 [Abstract] [Full Text]  
• Weston, C. F M (2008). Performance indicators in acute myocardial infarction: a proposal for the future assessment of good quality care. Heart 94: 1397-1401 [Full Text]  
• Steg, P. G., Kerner, A., Van de Werf, F., Lopez-Sendon, J., Gore, J. M., FitzGerald, G., Feldman, L. J., Anderson, F. A., Avezum, A., for the Global Registry of Acute Coronary Events (, (2008). Impact of In-Hospital Revascularization on Survival in Patients With Non-ST-Elevation Acute Coronary Syndrome and Congestive Heart Failure. Circulation 118: 1163-1171 [Abstract] [Full Text]  
• Gao, R, Patel, A, Gao, W, Hu, D, Huang, D, Kong, L, Qi, W, Wu, Y, Yang, Y, Harris, P, Algert, C, Groenestein, P, Turnbull, F, on behalf of the CPACS Investigators, (2008). Prospective observational study of acute coronary syndromes in China: practice patterns and outcomes. Heart 94: 554-560 [Abstract] [Full Text]  
• Reynolds, H. R., Hochman, J. S. (2008). Cardiogenic Shock: Current Concepts and Improving Outcomes. Circulation 117: 686-697 [Full Text]  
• Kapur, A., De Palma, R. (2007). Mortality after myocardial infarction in patients with diabetes mellitus. Heart 93: 1504-1506 [Abstract] [Full Text]  
• Gale, C. P., Manda, S. O., Hall, A. S. (2007). Are acute coronary syndromes risk models too complex?. Eur Heart J 28: 2175-2176 [Full Text]  
• Timmer, J. R., Ottervanger, J. P., de Boer, M.-J., Boersma, E., Grines, C. L., Westerhout, C. M., Simes, R. J., Granger, C. B., Zijlstra, F., for the Primary Coronary Angioplasty vs Thrombolys, (2007). Primary Percutaneous Coronary Intervention Compared With Fibrinolysis for Myocardial Infarction in Diabetes Mellitus: Results From the Primary Coronary Angioplasty vs Thrombolysis-2 Trial. Arch Intern Med 167: 1353-1359 [Abstract] [Full Text]  
• Authors/Task Force Members, , Bassand, J.-P., Hamm, C. W., Ardissino, D., Boersma, E., Budaj, A., Fernandez-Aviles, F., Fox, K. A.A., Hasdai, D., Ohman, E. M., Wallentin, L., Wijns, W., ESC Committee for Practice Guidelines (CPG), , Vahanian, A., Camm, J., De Caterina, R., Dean, V., Dickstein, K., Filippatos, G., Kristensen, S. D., Widimsky, P., McGregor, K., Sechtem, U., Tendera, M., Hellemans, I., Gomez, J. L. Z., Silber, S., Funck-Brentano, C., Document Reviewers, , Kristensen, S. D., Andreotti, F., Benzer, W., Bertrand, M., Betriu, A., De Caterina, R., DeSutter, J., Falk, V., Ortiz, A. F., Gitt, A., Hasin, Y., Huber, K., Kornowski, R., Lopez-Sendon, J., Morais, J., Nordrehaug, J. E., Silber, S., Steg, P. G., Thygesen, K., Tubaro, M., Turpie, A. G.G., Verheugt, F., Windecker, S. (2007). Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology. Eur Heart J 28: 1598-1660 [Full Text]  
• Neumann, F.-J., Buttner, H. J. (2007). Underuse of revascularisation in acute coronary syndromes. Heart 93: 147-148 [Abstract] [Full Text]