![]() ![]() ![]() Multicentre and prospective study, it is part of clinical audit that was conducted to evaluate all aspects of management of patients with NSTE-ACS. This study sought to investigate the adherence of cardiologists to international guidelines in managing NSTE-ACS patients in form of using risk stratification scores (TIMI and GRACE scores) in daily practice in Iraq and to determine if there is treatment-risk paradox in catheterising this population and the predictors of this paradox if present. Underuse of risk scores may explain this paradox, as health professionals disagree on the importance of cardiac risk scores used to decide on the management of NSTE-ACS patients. This phenomenon, often referred to as the ‘treatment-risk paradox’. It is noted that patients who can benefit mostly from treatment are not being treated because there is an exaggerated fear from treatment complications. *Intermediate risk category (diabetes, renal insufficiency, or left ventricular ejection fraction less than 40, post MI angina or prior CABG or GRACE score 109–140) should be catheterised within 72 h. *High risk patients (NSTEMI, dynamic ECG changes, GRACE score more than 140) should be catheterised within 24 h. *Very high-risk criteria patients (Shock, acute heart failure, ongoing chest pain, life threatening arrhythmia, mechanical complications, or recurrent dynamic Electrocardiogram changes) should be catheterised within 2 hours. This necessitates using objective risk stratification tools to guide management plan in NSTE-ACS with TIMI and GRACE scores being most reliable tools, proper risk assessment of NSTE-ACS patients is mandatory to guide the triage among alternative levels of hospital care (e.g., Coronary Care Unit vs hospital ward vs outpatient care), as well as decision and timing of intervention as following: Despite Non ST elevation myocardial infarction (NSTEMI) incidence continues to rise with greater improvement in outcomes of ACS patients in last decades, long term outcomes have not improved in NSTEMI at the same rate of ST elevation myocardial infarction (STEMI) a suggested explanation is depriving those with most benefit from intervention. This big killer CAD mainly presented as either chronic stable angina or acute coronary syndrome (ACS). Audit programs activation in middle eastern countries can inform policymakers to put a limit to the treatment-risk paradox for better cardiovascular care and outcomes.Īccording to WHO survey (2017) death from coronary artery disease (CAD) in Iraq reached about 18.5% of total deaths. The paradox did not only involve the very high-risk patients but also the very high-risk criteria like ongoing chest pain and cardiogenic shock predicted conservative approach, this highlights that the entire approach to patients with NSTE-ACS should be reconsidered, regardless of the use of risk scores in clinical practice. There is striking underuse of risk scores in practice that can contribute to treatment-risk paradox in managing NSTE-ACS in form of depriving those with higher risk from invasive strategy despite being the most beneficiaries. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach. Sixty percent of those with acute heart failure, 80.76% of those with ongoing chest pain, 85% of those with dynamic ST changes same as 80% of those with cardiogenic shock were treated conservatively. The immediate intervention in less than 2 hours was more to be used in low-risk categories while the high-risk and very high-risk patients whom were managed invasively were catheterized within >72 h or more frequently to be non-catheterized at all. Invasive strategy was adopted in 85.24 and 82.7% of low GRACE and TIMI risk categories respectively, while invasive approach used in 42.85 and 40% of high GRACE and TIMI risk categories respectively. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. Baseline characteristics were collected, TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores were calculated, management strategy as well as timing to intervention were recorded. Multicentre prospective study recruited NSTE-ACS patients. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice. Risk stratification is the cornerstone in managing patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS) and can attenuate the unjustified variability in treatment and guide the intervention decision notwithstanding its impact on better healthcare resources use. ![]()
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