80 Time to invasive coronary angiography and grace score calculation in patients presenting with NSTEMI at a district general hospital

Introduction Non-ST-elevation myocardial infarction (NSTEMI) is part of the wider spectrum of Acute Coronary Syndrome (ACS) and is the most common type of myocardial infarction in the UK. Patients with NSTEMI can be at low, intermediate or high risk of mortality or cardiovascular events depending on their presentation and the treatment approach can be different in low or intermediate/high risk groups. The Global Registry of Acute Coronary Events (GRACE) score helps predict these events at 6-months and has been recommended by National Institute for Health and Care Excellence (NICE) to be used as a guidance when deciding conservative management for low risk patients (predicted 6-month mortality ≤3) versus invasive coronary angiography (with follow-on PCI if indicated) within 72 hours in intermediate or high risk patients (predicted 6-month mortality >3%). European Society of Cardiology (ESC) latest guidelines outline that an early invasive strategy (<24 hours) should be considered in patients with high risk features; GRACE score >15%, dynamic ST-T changes or transient ST-segment elevation on ECG. Objectives A quality improvement project was undertaken to assess and improve adherence to GRACE score calculation in patients with NSTEMI at Scunthorpe General Hospital and whether those in intermediate/high risk groups are getting invasive coronary angiography (ICA) within 72 hours as per the NICE guidelines with reducing ICA service at this site over the years - Non-primary PCI service every weekday in 2021 to 3 days a week in 2022 to only diagnostic angiography 3 days a week in 2023. Method The data was collected retrospectively from the ICA requests August onwards of each year. A total of 90 patients were included over three years. GRACE score was checked in each request and where not available, minimum score was calculated from the information on presentation. Those with >3% score were then compared in each year for the time to ICA from the time of request. Results GRACE score was not mentioned in any of the 90 ICA requests. The gender distribution was about 2/3rd male to 1/3rd female patients in each year. 83% patients had ICA within 72 hours in 2021 and 2022 regardless of the GRACE score. This halved to 40% in 2023. 18 out of 30 patients had a score >3% in the first two years and 19 in the last. 89% of the intermediate/high risk patients got ICA within 72 hours in 2021 and 2022. In contrast, only 37% of the patients met this target in 2023. Conclusion The results clearly show that GRACE score is not incorporated in ICA requests. Furthermore, reducing the service has hugely impacted the care of the patients recently where they are being transferred to a PCI centre for it. An efficient system needs to be in place and we suggest that ICA requests should have a mandatory GRACE score and other high risk features in it so that the triaging team can identify intermediate/high risk patients and prioritise transfer so that the 72 hour target is met. Conflict of Interest No