Department of Medicine, Al Kindy College of Medicine, University of Baghdad, Baghdad, Iraq.
Iraqi Scentific Council of Cardiology/ Iraqi Board for Medical Specializations, Baghdad, Iraq.
BMC Health Serv Res. 2021 Sep 26;21(1):1015. doi: 10.1186/s12913-021-07034-7.
Risk stratification is the cornerstone in managing patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS) and can attenuate the unjustified variability in treatment and guide the intervention decision notwithstanding its impact on better healthcare resources use. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice.
Multicentre prospective study recruited NSTE-ACS patients. Baseline characteristics were collected, TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores were calculated, management strategy as well as timing to intervention were recorded.
n. = 150, 72% of them were males, mean age was (59 ± 12.32) years. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. Invasive strategy was adopted in 85.24 and 82.7% of low GRACE and TIMI risk categories respectively, while invasive approach used in 42.85 and 40% of high GRACE and TIMI risk categories respectively. The immediate intervention in less than 2 hours was more to be used in low-risk categories while the high-risk and very high-risk patients whom were managed invasively were catheterized within >72 h; or more frequently to be non-catheterized at all. Sixty percent of those with acute heart failure, 80.76% of those with ongoing chest pain, 85% of those with dynamic ST changes same as 80% of those with cardiogenic shock were treated conservatively. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach.
There is striking underuse of risk scores in practice that can contribute to treatment-risk paradox in managing NSTE-ACS in form of depriving those with higher risk from invasive strategy despite being the most beneficiaries. The paradox did not only involve the very high-risk patients but also the very high-risk criteria like ongoing chest pain and cardiogenic shock predicted conservative approach, this highlights that the entire approach to patients with NSTE-ACS should be reconsidered, regardless of the use of risk scores in clinical practice. Audit programs activation in middle eastern countries can inform policymakers to put a limit to the treatment-risk paradox for better cardiovascular care and outcomes.
风险分层是管理非 ST 段抬高型急性冠状动脉综合征（NSTE-ACS）患者的基石，可以减轻治疗中不必要的差异，并指导干预决策，同时改善医疗资源的利用。本研究旨在揭示 NSTE-ACS 患者风险分层和实践中干预决策的实际指南遵循情况。
多中心前瞻性研究纳入了 NSTE-ACS 患者。收集基线特征，计算 TIMI（心肌梗死溶栓）和 GRACE（全球急性冠状动脉事件注册）评分，记录管理策略和干预时机。
共纳入 150 例患者，其中 72%为男性，平均年龄（59±12.32）岁。5.3%的患者计算了 TIMI 评分，而无患者计算 GRACE 评分。低 GRACE 和 TIMI 风险组分别有 85.24%和 82.7%采用了侵入性策略，而高 GRACE 和 TIMI 风险组分别有 42.85%和 40%采用了侵入性策略。低危组更倾向于在 2 小时内进行即刻干预，而高危和极高危患者如果需要介入治疗，则在 72 小时后进行介入；或者更频繁地完全不进行介入。60%的急性心力衰竭患者、80.76%的持续胸痛患者、85%的动态 ST 段改变患者和 80%的心源性休克患者均接受保守治疗。多变量分析显示，年龄较大、持续胸痛和心源性休克与保守治疗相关。
实践中风险评分的使用明显不足，这可能导致 NSTE-ACS 管理中的治疗风险悖论，即剥夺了高危患者的侵入性治疗机会，尽管他们是最受益的患者。这种悖论不仅涉及极高危患者，还涉及极高危标准，如持续胸痛和心源性休克，这些标准预示着保守治疗策略，这突出表明，无论在临床实践中是否使用风险评分，都应重新考虑对 NSTE-ACS 患者的治疗方法。中东国家启动审核项目，可以为决策者提供信息，限制治疗风险悖论，以改善心血管护理和结局。
