Use of proven therapies in non-ST-elevation acute coronary syndromes according to evidence-based risk stratification
Identifieur interne : 009261 ( Main/Exploration ); précédent : 009260; suivant : 009262Use of proven therapies in non-ST-elevation acute coronary syndromes according to evidence-based risk stratification
Auteurs : Gustavo B. F. Oliveira [Brésil] ; Alvaro Avezum [Brésil] ; Frederick A. Jr Anderson [États-Unis] ; Andrzej Budaj [Pologne] ; Omar H. Dabbous [États-Unis] ; Shaun G. Goodman [Canada] ; Philippe Gabriel Steg [France] ; Robert J. Goldberg [États-Unis] ; David Brieger [Australie] ; Keith A. A. Fox [Royaume-Uni] ; Joel M. Gore [États-Unis] ; Christopher B. Granger [États-Unis]Source :
- The American heart journal [ 0002-8703 ] ; 2007.
Descripteurs français
- Pascal (Inist)
English descriptors
- KwdEn :
Abstract
Background Current guidelines advise the use of risk stratification to determine which'patients should receive more aggressive antithrombotic and invasive therapies. Our objective was to evaluate the relationship between risk stratification and therapeutic decision making in patients with non-ST-segment elevation acute coronary syndromes. Methods We analyzed data from 15026 patients with acute coronary syndrome who were enrolled into the GRACE registry between 1999 and 2003. We assessed the evidence-based use of antithrombotic therapy and early invasive strategy according to risk profile defined by baseline troponin elevation, presenting ST-segment depression, and GRACE risk score. Patients with possible contraindications were removed to define the use of therapies specifically among clearly eligible patients. Results Patients with elevated troponin were more likely to receive enoxaparin (60% vs 50.4%, respectively), GP llb/llla inhibitors (32.8% vs 17.6%), and to undergo catheterization (66% vs 54%) and percutaneous coronary intervention (37.4% vs 25.6%; all P <.0001). Patients with ST depression received modestly more enoxaparin and GP llb/llla than those without ST depression, but not more catheterization (P =.8) or percutaneous coronary intervention (P =.09). Highest risk patients were somewhat less likely to receive enoxaparin (P <.0001) and cardiac catheterization (P =.0002) according to GRACE risk deciles. Conclusions In spite of current guidelines recommending the use of selected therapies in high-risk patients, there is no clear correlation of use of effective therapies with overall risk profile even among eligible patients. Thus, there is substantial opportunity to improve use of effective therapies, especially in high-risk populations.
Affiliations:
- Australie, Brésil, Canada, France, Pologne, Royaume-Uni, États-Unis
- Nouvelle-Galles du Sud, Ontario, État de São Paulo, Île-de-France
- Paris, Sydney, São Paulo, Toronto
- Université de Toronto
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F." last="Oliveira">Gustavo B. F. Oliveira</name><affiliation wicri:level="3"><inist:fA14 i1="01"><s1>Dante Pazzanese Institute of Cardiology</s1><s2>Sao Paulo</s2><s3>BRA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></inist:fA14><country>Brésil</country><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author><author><name sortKey="Avezum, Alvaro" sort="Avezum, Alvaro" uniqKey="Avezum A" first="Alvaro" last="Avezum">Alvaro Avezum</name><affiliation wicri:level="3"><inist:fA14 i1="01"><s1>Dante Pazzanese Institute of Cardiology</s1><s2>Sao Paulo</s2><s3>BRA</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ></inist:fA14><country>Brésil</country><placeName><settlement type="city">São Paulo</settlement><region type="state">État de São Paulo</region></placeName></affiliation></author><author><name sortKey="Anderson, Frederick A Jr" sort="Anderson, Frederick A Jr" uniqKey="Anderson F" first="Frederick A. Jr" last="Anderson">Frederick A. Jr Anderson</name><affiliation wicri:level="1"><inist:fA14 i1="02"><s1>University of Massachusetts Medical School</s1><s2>Worcester, MA</s2><s3>USA</s3><sZ>3 aut.</sZ><sZ>5 aut.</sZ><sZ>8 aut.</sZ><sZ>11 aut.</sZ></inist:fA14><country>États-Unis</country><wicri:noRegion>University of Massachusetts Medical School</wicri:noRegion></affiliation></author><author><name sortKey="Budaj, Andrzej" sort="Budaj, Andrzej" uniqKey="Budaj A" first="Andrzej" last="Budaj">Andrzej Budaj</name><affiliation wicri:level="1"><inist:fA14 i1="03"><s1>Postgraduate Medical School, Grochowski Hospital</s1><s2>Warsaw</s2><s3>POL</s3><sZ>4 aut.</sZ></inist:fA14><country>Pologne</country><wicri:noRegion>Warsaw</wicri:noRegion></affiliation></author><author><name sortKey="Dabbous, Omar H" sort="Dabbous, Omar H" uniqKey="Dabbous O" first="Omar H." last="Dabbous">Omar H. Dabbous</name><affiliation wicri:level="1"><inist:fA14 i1="02"><s1>University of Massachusetts Medical School</s1><s2>Worcester, MA</s2><s3>USA</s3><sZ>3 aut.</sZ><sZ>5 aut.</sZ><sZ>8 aut.</sZ><sZ>11 aut.</sZ></inist:fA14><country>États-Unis</country><wicri:noRegion>University of Massachusetts Medical School</wicri:noRegion></affiliation></author><author><name sortKey="Goodman, Shaun G" sort="Goodman, Shaun G" uniqKey="Goodman S" first="Shaun G." last="Goodman">Shaun G. Goodman</name><affiliation wicri:level="4"><inist:fA14 i1="04"><s1>St. Michael's Hospital, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>6 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Gabriel Steg, Philippe" sort="Gabriel Steg, Philippe" uniqKey="Gabriel Steg P" first="Philippe" last="Gabriel Steg">Philippe Gabriel Steg</name><affiliation wicri:level="3"><inist:fA14 i1="05"><s1>Cardiology, Hôpital Bichat</s1><s2>Paris</s2><s3>FRA</s3><sZ>7 aut.</sZ></inist:fA14><country>France</country><placeName><region type="region">Île-de-France</region><region type="old region">Île-de-France</region><settlement type="city">Paris</settlement></placeName></affiliation></author><author><name sortKey="Goldberg, Robert J" sort="Goldberg, Robert J" uniqKey="Goldberg R" first="Robert J." last="Goldberg">Robert J. Goldberg</name><affiliation wicri:level="1"><inist:fA14 i1="02"><s1>University of Massachusetts Medical School</s1><s2>Worcester, MA</s2><s3>USA</s3><sZ>3 aut.</sZ><sZ>5 aut.</sZ><sZ>8 aut.</sZ><sZ>11 aut.</sZ></inist:fA14><country>États-Unis</country><wicri:noRegion>University of Massachusetts Medical School</wicri:noRegion></affiliation></author><author><name sortKey="Brieger, David" sort="Brieger, David" uniqKey="Brieger D" first="David" last="Brieger">David Brieger</name><affiliation wicri:level="3"><inist:fA14 i1="06"><s1>Coronary Care Unit, Concord Hospital</s1><s2>Sydney</s2><s3>AUS</s3><sZ>9 aut.</sZ></inist:fA14><country>Australie</country><placeName><settlement type="city">Sydney</settlement><region type="état">Nouvelle-Galles du Sud</region></placeName></affiliation></author><author><name sortKey="Fox, Keith A A" sort="Fox, Keith A A" uniqKey="Fox K" first="Keith A. A." last="Fox">Keith A. A. Fox</name><affiliation wicri:level="1"><inist:fA14 i1="07"><s1>The University and The Royal Infirmary of Edinburgh</s1><s2>Edinburgh, Scotland</s2><s3>GBR</s3><sZ>10 aut.</sZ></inist:fA14><country>Royaume-Uni</country><wicri:noRegion>The University and The Royal Infirmary of Edinburgh</wicri:noRegion></affiliation></author><author><name sortKey="Gore, Joel M" sort="Gore, Joel M" uniqKey="Gore J" first="Joel M." last="Gore">Joel M. Gore</name><affiliation wicri:level="1"><inist:fA14 i1="02"><s1>University of Massachusetts Medical School</s1><s2>Worcester, MA</s2><s3>USA</s3><sZ>3 aut.</sZ><sZ>5 aut.</sZ><sZ>8 aut.</sZ><sZ>11 aut.</sZ></inist:fA14><country>États-Unis</country><wicri:noRegion>University of Massachusetts Medical School</wicri:noRegion></affiliation></author><author><name sortKey="Granger, Christopher B" sort="Granger, Christopher B" uniqKey="Granger C" first="Christopher B." last="Granger">Christopher B. Granger</name><affiliation wicri:level="1"><inist:fA14 i1="08"><s1>Duke University Medical Center</s1><s2>Durham, NC</s2><s3>USA</s3><sZ>12 aut.</sZ></inist:fA14><country>États-Unis</country><wicri:noRegion>Duke University Medical Center</wicri:noRegion></affiliation></author></analytic><series><title level="j" type="main">The American heart journal</title><title level="j" type="abbreviated">Am. heart j.</title><idno type="ISSN">0002-8703</idno><imprint><date when="2007">2007</date></imprint></series></biblStruct></sourceDesc><seriesStmt><title level="j" type="main">The American heart journal</title><title level="j" type="abbreviated">Am. heart j.</title><idno type="ISSN">0002-8703</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Cardiology</term><term>Circulatory system</term><term>Evidence-based medicine</term><term>Myocardial infarction</term><term>Phlebology</term><term>Risk</term><term>Risk factor</term><term>ST elevation</term><term>Stratification</term><term>Therapy</term><term>Treatment</term><term>Use</term><term>Variant angina</term></keywords><keywords scheme="Pascal" xml:lang="fr"><term>Infarctus du myocarde</term><term>Angor instable</term><term>Utilisation</term><term>Traitement</term><term>Thérapie</term><term>Susdécalage ST</term><term>Médecine factuelle</term><term>Facteur risque</term><term>Risque</term><term>Stratification</term><term>Appareil circulatoire</term><term>Cardiologie</term><term>Phlébologie</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Background Current guidelines advise the use of risk stratification to determine which'patients should receive more aggressive antithrombotic and invasive therapies. Our objective was to evaluate the relationship between risk stratification and therapeutic decision making in patients with non-ST-segment elevation acute coronary syndromes. Methods We analyzed data from 15026 patients with acute coronary syndrome who were enrolled into the GRACE registry between 1999 and 2003. We assessed the evidence-based use of antithrombotic therapy and early invasive strategy according to risk profile defined by baseline troponin elevation, presenting ST-segment depression, and GRACE risk score. Patients with possible contraindications were removed to define the use of therapies specifically among clearly eligible patients. Results Patients with elevated troponin were more likely to receive enoxaparin (60% vs 50.4%, respectively), GP llb/llla inhibitors (32.8% vs 17.6%), and to undergo catheterization (66% vs 54%) and percutaneous coronary intervention (37.4% vs 25.6%; all P <.0001). Patients with ST depression received modestly more enoxaparin and GP llb/llla than those without ST depression, but not more catheterization (P =.8) or percutaneous coronary intervention (P =.09). Highest risk patients were somewhat less likely to receive enoxaparin (P <.0001) and cardiac catheterization (P =.0002) according to GRACE risk deciles. Conclusions In spite of current guidelines recommending the use of selected therapies in high-risk patients, there is no clear correlation of use of effective therapies with overall risk profile even among eligible patients. Thus, there is substantial opportunity to improve use of effective therapies, especially in high-risk populations.</div></front></TEI><affiliations><list><country><li>Australie</li><li>Brésil</li><li>Canada</li><li>France</li><li>Pologne</li><li>Royaume-Uni</li><li>États-Unis</li></country><region><li>Nouvelle-Galles du Sud</li><li>Ontario</li><li>État de São Paulo</li><li>Île-de-France</li></region><settlement><li>Paris</li><li>Sydney</li><li>São Paulo</li><li>Toronto</li></settlement><orgName><li>Université de Toronto</li></orgName></list><tree><country name="Brésil"><region name="État de São Paulo"><name sortKey="Oliveira, Gustavo B F" sort="Oliveira, Gustavo B F" uniqKey="Oliveira G" first="Gustavo B. F." last="Oliveira">Gustavo B. F. Oliveira</name></region><name sortKey="Avezum, Alvaro" sort="Avezum, Alvaro" uniqKey="Avezum A" first="Alvaro" last="Avezum">Alvaro Avezum</name></country><country name="États-Unis"><noRegion><name sortKey="Anderson, Frederick A Jr" sort="Anderson, Frederick A Jr" uniqKey="Anderson F" first="Frederick A. Jr" last="Anderson">Frederick A. Jr Anderson</name></noRegion><name sortKey="Dabbous, Omar H" sort="Dabbous, Omar H" uniqKey="Dabbous O" first="Omar H." last="Dabbous">Omar H. Dabbous</name><name sortKey="Goldberg, Robert J" sort="Goldberg, Robert J" uniqKey="Goldberg R" first="Robert J." last="Goldberg">Robert J. Goldberg</name><name sortKey="Gore, Joel M" sort="Gore, Joel M" uniqKey="Gore J" first="Joel M." last="Gore">Joel M. Gore</name><name sortKey="Granger, Christopher B" sort="Granger, Christopher B" uniqKey="Granger C" first="Christopher B." last="Granger">Christopher B. Granger</name></country><country name="Pologne"><noRegion><name sortKey="Budaj, Andrzej" sort="Budaj, Andrzej" uniqKey="Budaj A" first="Andrzej" last="Budaj">Andrzej Budaj</name></noRegion></country><country name="Canada"><region name="Ontario"><name sortKey="Goodman, Shaun G" sort="Goodman, Shaun G" uniqKey="Goodman S" first="Shaun G." last="Goodman">Shaun G. Goodman</name></region></country><country name="France"><region name="Île-de-France"><name sortKey="Gabriel Steg, Philippe" sort="Gabriel Steg, Philippe" uniqKey="Gabriel Steg P" first="Philippe" last="Gabriel Steg">Philippe Gabriel Steg</name></region></country><country name="Australie"><region name="Nouvelle-Galles du Sud"><name sortKey="Brieger, David" sort="Brieger, David" uniqKey="Brieger D" first="David" last="Brieger">David Brieger</name></region></country><country name="Royaume-Uni"><noRegion><name sortKey="Fox, Keith A A" sort="Fox, Keith A A" uniqKey="Fox K" first="Keith A. A." last="Fox">Keith A. A. 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