Challenging times

Access to diagnostic coronary angiography and, if necessary, revascularisation within 72 hours of presentation is a class 1A indication in North American and European guidelines for those with high or intermediate risk features for poor clinical outcome. This strong recommendation is based on contemporary randomised trials, including meta-analyses3 4 comparing a systematic invasive strategy against a default conservative medical strategy with intervention only in the event of refractory ischaemia. Cost-effectiveness analyses also indicate that targeting those at highest risk is of economic value.5 6 Early invasive strategies (<24 hours) remain an area for further investigation and debate but evidence is rapidly accumulating that this has clinical benefit. Nevertheless, despite the wealth of data to inform us, there has been difficulty in translating guidance into practice.

Amazing GRACE

The Global Registry of Acute Coronary Events (GRACE) gives us insight into this disconnection. It is the largest database of contemporary management with over 100 000 patient records collected over the last decade. By involving 30 countries across four continents it is a truly international cohort with enviable external validity.

It has the highest c-statistic of any clinical risk score to date with predictive outcomes to 6 months from the index presentation.

Swanson et al, in the February issue of Heart, have analysed the data from the patients in the GRACE registry.7 The investigators found that a staggering 43% …