Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands

Q: What are the key findings of this study?

Elevated troponin levels (OR 66.90, p≤0.001) and typical ischaemic ECG changes (OR 15.39, p≤0.001) strongly increased cardiologists' decisions to perform coronary angiography in suspected NST-ACS.

Q: What is the clinical evidence from this study?

Study design: Cross-Sectional. Population: Suspected Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) (n=111). Intervention: Clinical factors and GRACE 2.0 cardiac risk score in clinical vignettes (e.g., elevated troponin levels) vs. Normal reference clinical factors (e.g., normal troponin levels) or vignettes without a risk score. Primary outcome: Decision to perform coronary angiography within 72 hours of admission (Group 1 multivariable effect of elevated vs normal troponin) (OR 66.90, 95% CI 26.29 to 170.25, p=≤0.001).

Q: What does this research mean for the field?

Cardiologists' decisions to perform coronary angiography in suspected non-ST-elevation acute coronary syndrome are driven predominantly by elevated troponin levels and typical ischaemic ECG changes, whereas severe renal dysfunction substantially reduces the likelihood of ordering angiography. Novelty: ClaimNovelty.NOVEL_FINDING. Consensus alignment: ConsensusAlignment.NEUTRAL.

Josien Engel; Judith M. Poldervaart; Ineke van der Wulp; Johannes B. Reitsma; Martine C. de Bruijne; Jeroen J. H. Bunge; Maarten J. Cramer; Wouter J. Tietge; Ruben Uijlings; Cordula Wagner

doi:10.1136/bmjopen-2016-011213

January 1, 2017BMJ OpenOpen Access

Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands

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Key result

Elevated troponin is linked to ~67-fold higher odds of invasive angiography referral in suspected NST-ACS.

OR 66.90
95% CI 26.29 to 170.25
P≤0.001
n=111

Figures

Why the study?

How do different clinical characteristics and the presence of risk scores influence the decision-making of cardiologists regarding performing coronary angiography in patients with suspected NST-ACS?

Study Design

Type

Cross-Sectional (n=111)

Randomization

Random allocation to survey vignette blocks and risk score presence groups

Multicenter

Yes

Structured PICO

How do different clinical characteristics and the presence of risk scores influence the decision-making of cardiologists regarding performing coronary angiography in patients with suspected NST-ACS?

P

Population

111 active Dutch cardiologists (median age ~50 years, 17.1% female) evaluating clinical vignettes of patients with suspected NST-ACS.

E

Exposure

Clinical vignettes with a risk score present

C

Comparator

Clinical vignettes without a risk score present

O

Outcome

Decision to perform in-hospital coronary angiography (≤72 hours after patient admission)

Main Result

Odds Ratio: 66.9 (95% CI 26.29–170.25)

Absolute Event Rate: 80.6% vs 26.9%

p-value: p=≤0.001

When deciding to perform in-hospital coronary angiography for suspected NST-ACS, cardiologists rely primarily on troponin levels, ECG changes, and renal function, showing hesitancy in patients with severe renal dysfunction or elderly patients with high-risk scores.

Limitations

Low survey response rate (14% in group 1 and 13% in group 2), falling short of the target sample size
Potential selection bias toward male cardiologists aged 50 years or older with >10 years of experience
Strong confounding between patient age and cardiac risk score prevented independent assessment of their separate contributions
Vignette-based decisions was limited to 7 attributes and may differ from real-life clinical practice
Decision timeframe was fixed to within 72 hours rather than differentiating immediate or <24-hour angiography

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Implication

Reliance on troponin and ECG drives NST-ACS angiography decisions; leaves open whether risk scores should modify choices in elderly or renal impairment.

Abstract

OBJECTIVE: Cardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS. DESIGN: A web-based survey containing clinical vignettes. SETTING AND PARTICIPANTS: Registered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes 'without' a risk score present, while group 2 completed vignettes 'with' a risk score present. RESULTS: 129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores. CONCLUSIONS: When deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.

Discussion

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Cite This Study

Engel et al. (2017) conducted a cross-sectional in Suspected Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) (n=111). Clinical factors and GRACE 2.0 cardiac risk score in clinical vignettes (e.g., elevated troponin levels) vs. Normal reference clinical factors (e.g., normal troponin levels) or vignettes without a risk score was evaluated on Decision to perform coronary angiography within 72 hours of admission (Group 1 multivariable effect of elevated vs normal troponin) (OR 66.90, 95% CI 26.29 to 170.25, p=≤0.001). Elevated troponin levels (OR 66.90, p≤0.001) and typical ischaemic ECG changes (OR 15.39, p≤0.001) strongly increased cardiologists' decisions to perform coronary angiography in suspected NST-ACS.

synapsesocial.com/papers/6a707b54e36a167817e2455d https://doi.org/10.1136/bmjopen-2016-011213

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Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands

Figures

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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