Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The global registry of acute coronary events (GRACE)

Keith AA Fox ^1*, Frederick A Anderson ², Omar H Dabbous ², Philippe Gabriel Steg ³, Jose L Lopez-Sendon ⁴, Frans Van de Werf ⁵, Andrzej Budaj ⁶, Enrique P Gurfinkel ⁷, Shaun G Goodman ⁸ and David Brieger ⁹

¹ University of Edinburgh, United Kingdom
² UMASS Medical School, United States
³ Hopital Bichat, France
⁴ Hospital Universitario gregorio Marañon, Spain
⁵ Gasthuisberg University Hospital, Belgium
⁶ Grochowski Hospital, Poland
⁷ ICYCC Favaloro Foundation, Argentina
⁸ St. Michael's Hospital, Canada
⁹ Concord Hospital, Australia

^* To whom correspondence should be addressed. E-mail: k.a.a.fox{at}ed.ac.uk.

Accepted 24 May 2006

Abstract

Background: Randomized trial evidence supports the use of an interventional strategy in higher-risk patients with an acute coronary syndrome (ACS).

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

Methods: GRACE 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 non-ST elevation ACS underwent percutaneous coronary intervention (PCI) (53.7% in ST-segment elevation myocardial infarction [STEMI]) and 7.2% underwent 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, elevated 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 and 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, and 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 revascularization procedures, in contrast to current international practice.

Keywords: acute coronary syndrome, revascularization, risk stratification

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