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Chow C, Doll J. Contemporary Risk Models for In-Hospital and 30-Day Mortality After Percutaneous Coronary Intervention. Curr Cardiol Rep 2024; 26:451-457. [PMID: 38592570 DOI: 10.1007/s11886-024-02047-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Risk models for mortality after percutaneous coronary intervention (PCI) are underutilized in clinical practice though they may be useful during informed consent, risk mitigation planning, and risk adjustment of hospital and operator outcomes. This review analyzed contemporary risk models for in-hospital and 30-day mortality after PCI. RECENT FINDINGS We reviewed eight contemporary risk models. Age, sex, hemodynamic status, acute coronary syndrome type, heart failure, and kidney disease were consistently found to be independent risk factors for mortality. These models provided good discrimination (C-statistic 0.85-0.95) for both pre-catheterization and comprehensive risk models that included anatomic variables. There are several excellent models for PCI mortality risk prediction. Choice of the model will depend on the use case and population, though the CathPCI model should be the default for in-hospital mortality risk prediction in the United States. Future interventions should focus on the integration of risk prediction into clinical care.
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Affiliation(s)
- Christine Chow
- Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jacob Doll
- Department of Medicine, University of Washington, Seattle, WA, USA.
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2
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Fanaroff AC, Wang TY. Risk Prediction in Percutaneous Coronary Intervention: Solving the Last Mile Problem. Circ Cardiovasc Interv 2022; 15:e012262. [PMID: 35861801 DOI: 10.1161/circinterventions.122.012262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Alexander C Fanaroff
- Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Leonard Davis Institute, and Cardiovascular Medicine Division, University of Pennsylvania, Philadelphia (A.C.F.)
| | - Tracy Y Wang
- Division of Cardiovascular Medicine and Duke Clinical Research Institute, Duke University, Durham, NC (T.Y.W.)
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Gullick J, Wu J, Chew D, Gale C, Yan AT, Goodman SG, Waters D, Hyun K, Brieger D. Objective risk assessment vs standard care for acute coronary syndromes-The Australian GRACE Risk tool Implementation Study (AGRIS): a process evaluation. BMC Health Serv Res 2022; 22:380. [PMID: 35317816 PMCID: PMC8941820 DOI: 10.1186/s12913-022-07750-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 03/02/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Structured risk-stratification to guide clinician assessment and engagement with evidence-based therapies may reduce care variance and improve patient outcomes for Acute Coronary Syndrome (ACS). The Australian Grace Risk score Intervention Study (AGRIS) explored the impact of the GRACE Risk Tool for stratification of ischaemic and bleeding risk in ACS. While hospitals in the active arm had a higher overall rate of invasive ACS management, there was neutral impact on important secondary prevention prescriptions/referrals, hospital performance measures, myocardial infarction and 12-month mortality leading to early trial cessation. Given the Grace Risk Tool is under investigation internationally, this process evaluation study provides important insights into the possible contribution of implementation fidelity on the AGRIS study findings. METHODS Using maximum variation sampling, five hospitals were selected from the 12 centres enrolled in the active arm of AGRIS. From these facilities, 16 local implementation stakeholders (Cardiology advanced practice nurses, junior and senior doctors, study coordinators) consented to a semi-structured interview guided by the Theoretical Domains Framework. Directed Content Analysis of qualitative data was structured using the Capability/Opportunity/Motivation-Behaviour (COM-B) model. RESULTS Physical capability was enhanced by tool usability. While local stakeholders supported educating frontline clinicians, non-cardiology clinicians struggled with specialist terminology. Physical opportunity was enhanced by the paper-based format but was hampered when busy clinicians viewed risk-stratification as one more thing to do, or when form visibility was neglected. Social opportunity was supported by a culture of research/evidence yet challenged by clinical workflow and rotating medical officers. Automatic motivation was strengthened by positive reinforcement. Reflective motivation revealed the GRACE Risk Tool as supporting but potentially overriding clinical judgment. Divergent professional roles and identity were a major barrier to integration of risk-stratification into routine Emergency Department practice. The cumulative result revealed poor form completion behaviors and a failure to embed risk-stratification into routine patient assessment, communication, documentation, and clinical practice behaviors. CONCLUSIONS Numerous factors negatively influenced AGRIS implementation fidelity. Given the prominence of risk assessment recommendations in United States, European and Australian guidelines, strategies that strengthen collaboration with Emergency Departments and integrate automated processes for risk-stratification may improve future translation internationally.
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Affiliation(s)
- Janice Gullick
- Susan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - John Wu
- Susan Wakil School of Nursing & Midwifery, and Site Services, University of Sydney Library, University of Sydney, Sydney, NSW Australia
| | - Derek Chew
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, Australia
| | - Chris Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, England
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, St Michael’s Hospital, Toronto, ON Canada
| | - Shaun G. Goodman
- Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Donna Waters
- Susan Wakil School of Nursing & Midwifery, Faculty of Medicine and Health, University of Sydney, Sydney, NSW Australia
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
- Concord Repatriation General Hospital, ANZAC Research Institute, Concord West, Australia
| | - David Brieger
- Concord Clinical School, Concord Repatriation General Hospital, ANZAC Research Institute, Concord West, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, +61 2 9767 5000 Australia
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Dakhil ZA, Farhan HA. Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq. BMC Health Serv Res 2021; 21:1015. [PMID: 34565377 PMCID: PMC8474949 DOI: 10.1186/s12913-021-07034-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 09/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background 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. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice. Methods Multicentre prospective study recruited NSTE-ACS patients. 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. Results n. = 150, 72% of them were males, mean age was (59 ± 12.32) years. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. 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. 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. 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. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach. Conclusions 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. 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. 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.
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Affiliation(s)
- Zainab Atiyah Dakhil
- Department of Medicine, Al Kindy College of Medicine, University of Baghdad, Baghdad, Iraq.
| | - Hasan Ali Farhan
- Iraqi Scentific Council of Cardiology/ Iraqi Board for Medical Specializations, Baghdad, Iraq.,Baghdad Heart Centre/ Medical City, Baghdad, Iraq
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The risk-treatment paradox in non-ST-elevation myocardial infarction patients according to their estimated GRACE risk. Int J Cardiol 2018; 272:26-32. [DOI: 10.1016/j.ijcard.2018.08.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 08/06/2018] [Indexed: 12/22/2022]
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Engel J, Damen NL, van der Wulp I, de Bruijne MC, Wagner C. Adherence to Cardiac Practice Guidelines in the Management of Non-ST-Elevation Acute Coronary Syndromes: A Systematic Literature Review. Curr Cardiol Rev 2017; 13:3-27. [PMID: 27142050 PMCID: PMC5324326 DOI: 10.2174/1573403x12666160504100025] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In the management of non-ST-elevation acute coronary syndrome (NSTACS) a gap between guideline-recommended care and actual practice has been reported. A systematic overview of the actual extent of this gap, its potential impact on patient-outcomes, and influential factors is lacking. OBJECTIVE To examine the extent of guideline adherence, to study associations with the occurrence of adverse cardiac events, and to identify factors associated with guideline adherence. METHOD Systematic literature review, for which PUBMED, EMBASE, CINAHL, and the Cochrane library were searched until March 2016. Further, a manual search was performed using reference lists of included studies. Two reviewers independently performed quality-assessment and data extraction of the eligible studies. RESULTS Adherence rates varied widely within and between 45 eligible studies, ranging from less than 5.0 % to more than 95.0 % for recommendations on acute and discharge pharmacological treatment, 34.3 % - 93.0 % for risk stratification, and 16.0 % - 95.8 % for performing coronary angiography. Seven studies indicated that higher adherence rates were associated with lower mortality. Several patient-related (e.g. age, gender, co-morbidities) and organization-related (e.g. teaching hospital) factors influencing adherence were identified. CONCLUSION This review showed wide variation in guideline adherence, with a substantial proportion of NST-ACS patients possibly not receiving guideline-recommended care. Consequently, lower adherence might be associated with a higher risk for poor prognosis. Future research should further investigate the complex nature of guideline adherence in NST-ACS, its impact on clinical care, and factors influencing adherence. This knowledge is essential to optimize clinical management of NSTACS patients and could guide future quality improvement initiatives.
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Affiliation(s)
- Josien Engel
- EMGO Institute for Health and Care Research, Department of Public and Occupational Health, VU University Medical Center. Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands
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Engel J, Poldervaart JM, van der Wulp I, Reitsma JB, de Bruijne MC, Bunge JJH, Cramer MJ, Tietge WJ, Uijlings R, Wagner C. Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands. BMJ Open 2017; 7:e011213. [PMID: 28104706 PMCID: PMC5253531 DOI: 10.1136/bmjopen-2016-011213] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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.
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Affiliation(s)
- Josien Engel
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Judith M Poldervaart
- Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ineke van der Wulp
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Johannes B Reitsma
- Julius Center for Health Sciences and Primary care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Jeroen J H Bunge
- Department of Intensive Care, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maarten J Cramer
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J Tietge
- Department of Cardiology, Alrijne Ziekenhuis, Leiden, The Netherlands
| | - Ruben Uijlings
- Department of Cardiology, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands
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Waters DD, Arsenault BJ. Predicting Prognosis in Acute Coronary Syndromes: Makeover Time for TIMI and GRACE? Can J Cardiol 2016; 32:1290-1293. [PMID: 27062237 DOI: 10.1016/j.cjca.2016.02.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 02/15/2016] [Accepted: 02/15/2016] [Indexed: 12/22/2022] Open
Affiliation(s)
- David D Waters
- Division of Cardiology, San Francisco General Hospital, and the Department of Medicine, University of California, San Francisco, California, USA.
| | - Benoit J Arsenault
- Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Québec, Québec, Canada
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