• Andrew T Yan, Raymond T Yan, Mary Tan, Anthony Fung, Eric A Cohen, David H Fitchett, Anatoly Langer, Shaun G Goodman, and Canadian Acute Coronary Syndromes 1 and 2 Registry Investigators.
• Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada M5B 1W8.
• Arch Intern Med. 2007 May 28; 167 (10): 100910161009-16.

BackgroundRandomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs.MethodsWe evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality).ResultsAlthough in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications.ConclusionsDespite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management.

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