June 6, 2006Open Access
Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE)
Key Result
In patients with acute coronary syndromes, PCI was performed less frequently in high-risk (25% non-STEMI, 41% STEMI) than low-risk patients (40% non-STEMI, 60% STEMI), despite higher mortality.
Study Design
Type
Cohort (n=24,189)
Multicenter
Yes
Structured PICO
Does the likelihood of undergoing revascularization in acute coronary syndromes correlate with patient risk characteristics?
P
Population
24,189 patients with acute coronary syndromes enrolled at 73 multinational hospitals with on-site angiographic facilities.
E
Exposure
Percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)
O
Outcome
Rate of revascularization (PCI or CABG) stratified by GRACE risk score
In international practice, a treatment-risk paradox exists where lower-risk ACS patients are more likely to undergo PCI than higher-risk patients who have the highest mortality.
Abstract
OBJECTIVE: To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies. METHODS: GRACE (Global Registry of Acute Coronary Events) 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 a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (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, raised 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, 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. 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 revascularisation procedures, in contrast to current international practice.
Cite This Study
Fox et al. (Tue,) conducted a cohort in Acute coronary syndromes (n=24,189). Patient risk status (GRACE risk score) vs. Low-risk status was evaluated on Performance of percutaneous coronary intervention (PCI) across risk strata. In patients with acute coronary syndromes, PCI was performed less frequently in high-risk (25% non-STEMI, 41% STEMI) than low-risk patients (40% non-STEMI, 60% STEMI), despite higher mortality.