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An acute coronary syndrome (ACS) risk stratification tool failed to improve either adherence to treatment guidelines or reduce the incidence of adverse cardiovascular outcomes compared to standard care, according to a recent cluster randomised controlled trial.
Non-ST segment elevation ACS (NSTEACS), which comprises non-ST elevation myocardial infarction (MI) and unstable angina, is a leading cause of disability, hospital admission and death. The Global Registry of Acute Coronary Events (GRACE) risk score (GRS) is designed to stratify risk in patients with ACS and provides an excellent ability to assess the risk for death.
In fact, optimal use of guideline-indicated care for non-ST-elevation myocardial infarction has previously been associated with greater survival gains. However, whether in practice using GRS leads to greater adherence to NSTEACS treatment guidelines and reduces the level of adverse cardiovascular sequalae was uncertain.
In the current study, published in the BMJ, researchers sought to determine if risk stratification using the GRS in patients presenting to hospital with suspected NSTEACS, enhanced the adoption of guideline-recommended therapy and reduced adverse cardiovascular outcomes.
Hospitals were randomised equally to patient management by either standard care or according to the GRS. The primary outcomes of interest were use of guideline recommended management and the time to a composite of cardiovascular death, non-fatal myocardial infarction, new onset heart failure hospital admission, and readmission for a cardiovascular event.
NSTEACS and the GRACE risk score
A total of 3,050 participants with a mean age of 65.7 years (69% female) were recruited and 1,440 were randomised to GRS care.
The uptake of guideline-recommended processes was not significantly different between the GRS and standard care groups (odds ratio, OR = 1.16, 95% CI 0.70 – 1.92, p = 0.56). In addition, the time to the first composite cardiac event was not significantly improved by the use of the GRS (hazard ratio, HR = 0.89, 95% CI 0.68 – 1.16, p = 0.37).
Secondary outcomes of interest included the EQ-5D-5L quality of life measure and the mean duration of the hospital admission for NSTEACS. As with the primary outcome, these metrics were not significantly different between the two groups.
The researchers concluded that use of the GRS score failed to improve guideline recommended management for NSTEACS or reduce a composite of adverse cardiovascular outcomes.
