ACS revascularization practices not based on patient risk characteristics

Feb 19, 2007

NEW YORK (Reuters Health), Feb 20 - Data in a multinational registry indicate that, contrary to published guidelines, low-risk patients with acute coronary syndromes (ACS) are more likely to receive percutaneous coronary interventions than those at high risk.

Current European and North American guidelines advocate revascularization for moderate- or high-risk patients with ACS, but not for low-risk patients, Dr. Keith A. A. Fox, from the University of Edinburgh in the U.K., and associates explain in the February issue of Heart.

To determine how patients with MI or unstable angina are being treated, the team examined data from the multinational Global Registry of Acute Coronary Events (GRACE). The registry includes data from 14 countries in North and South America, Europe, Australia and New Zealand.

The study included nearly 25,000 patients admitted to 73 hospitals with onsite angiographic facilities between 1999 and 2004.

The hospitals were classified according to rates of angiography in patients with MI. The patients were stratified into low-, medium-, and high-risk categories based on their GRACE score for risk of in-hospital death.

Among low-risk patients, the frequency of percutaneous coronary interventions ranged from 37.2% at hospitals with the lowest angiography rates, to 57.6% and 77.7% at hospitals in the medium and high rates.

In contrast, rates of interventions among high-risk patients were 16.0%, 33.3%, and 50.7%, respectively, the researchers report.

The findings were consistent across geographic regions, healthcare systems, and the aggressiveness of hospitals' angiography strategies.

In an accompanying editorial, Dr. F.-J. Neumann and Dr. H. J. Büttner, from Herz-Zentrum Bad Krozingen in Germany, comment that the "low-risk" patients in the study by Fox et al had to be at relatively high risk to have been entered into the GRACE registry, so revascularizations were probably appropriate, and not likely to represent overuse of percutaneous coronary interventions.

Furthermore, while revascularization rates among high-risk patients may have been suboptimal, the editorialists point out that many of those patients may not have been appropriate candidates because of their high risk and comorbidities, and therefore it can be assumed that the clinicians "did not miss the optimum to a large degree."

Last Updated: 2007-02-19 9:47:55 -0400 (Reuters Health)

Heart 2007;93:177-182,147-148.

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