Relation between baseline risk and treatment decisions in non-ST elevation acute coronary syndromes: an examination of international practice patterns.
To examine the interaction between ST segment depression on the baseline ECG and subsequent in-hospital revascularisation on six month mortality among patients with non-ST elevation acute coronary syndromes. To examine whether ST segment depression influenced clinical decision making and whether there was international variation in the use of cardiac procedures across ST segment depression categories.
11 453 patients enrolled in GUSTO-IIB (global use of strategies to open occluded coronary arteries), PARAGON (platelet IIb/IIIa antagonism for the reduction of acute coronary syndrome events in a global organisation network) -A, and PARAGON-B were studied. Patients were categorised as having no ST segment depression, 1 mm ST segment depression in two contiguous leads, and ST segment depression > or = 2 mm in two contiguous leads. International practice across four geographic regions was examined: USA, Canada, Europe, and Australia/New Zealand.
Revascularisation appeared to have no impact on survival among patients with no ST segment depression; however, revascularisation was associated with a significant survival benefit among patients with ST segment depression > or = 1 mm. There was an inverse relation between the extent of ST segment depression and the use of angiography as well as angioplasty (p or = 2 mm were more likely to undergo bypass surgery. The only significant trend of increasing use of revascularisation procedures with increasing ST segment depression was observed in the USA.
International practice patterns in procedure use appear to be insensitive to the extent of ST segment depression. Major opportunities for more efficient delivery of care exist in all regions.
Notes
Cites: Eur Heart J. 2002 Jan;23(1):41-911741361
Cites: J Am Coll Cardiol. 2001 Oct;38(4):969-7611583866
Cites: Lancet. 2002 Sep 7;360(9335):738-912241827
Cites: J Am Coll Cardiol. 2002 Dec 4;40(11):1895-90112475447
Cites: Eur Heart J. 2002 Dec;23(23):1809-4012503543
Cites: J Am Coll Cardiol. 2003 Feb 5;41(3):371-8012575962
Cites: J Am Coll Cardiol. 2003 Mar 19;41(6):905-1512651033
Cites: J Clin Oncol. 1983 Nov;1(11):710-96668489
Cites: N Engl J Med. 1996 Sep 12;335(11):775-828778585
Cites: Circulation. 1998 Jun 23;97(24):2386-959641689
Cites: Lancet. 1998 Aug 15;352(9127):507-149716054
Cites: Circulation. 1998 Nov 10;98(19):2004-99808597
Cites: Am Heart J. 1999 Jan;137(1):24-339878933
Cites: Am J Cardiol. 1999 Aug 15;84(4):379-8510468072
Cites: Lancet. 1999 Aug 28;354(9180):708-1510475181
Cites: Circulation. 2002 Jan 22;105(3):316-2111804986
Cites: Eur Heart J. 2000 Mar;21(5):371-8110666351
Cites: Eur Heart J. 2000 Sep;21(17):1433-910952835
Cites: J Am Coll Cardiol. 2000 Sep;36(3):970-106210987629
Cites: N Engl J Med. 2001 Jun 21;344(25):1879-8711419424
Cites: Circulation. 2001 Jun 19;103(24):2891-611413076
Cites: J Am Coll Cardiol. 2001 Jul;38(1):64-7111451297