Treatment for NSTEMI Fails to Match Risk for Mortality, Major Bleeding

A new analysis of NSTEMI patients in the National Cardiovascular Data Registry published in the American Heart Journal finds that patients at greatest risk for mortality and major bleeding are less likely to receive appropriate care.

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The analysis assessed the risk of mortality and acute bleeding in 61,366 NSTEMI patients across 237 centers enrolled in the NCDR’s ACTION Registry-GWTG from January 2007 through March 2009. Overall, data showed patients at high risk for morality and major bleeding were least likely to receive guideline-based pharmacotherapy (clopidogrel, glycoprotein IIb/IIIa inhibitors or bivalirudin) within 24 hours of admission (p<0.01 for all) or have early cardiac catheterization (p<0.001). Patients at highest risk were also the most likely to receive excessive doses of antithrombotic agents (p<0.001) during hospitalization and least likely to receive clopidogrel and statins at discharge (<0.01). Conversely, patients at low risk for mortality and major bleeding were more likely to receive the most intensive pharmacotherapy and angiography.

"We observed that 40 percent of patients were at higher than average risk for death as well as major bleeding," wrote lead author Nihar Desai MD, MPH, Brigham and Women's Hospital and Harvard Medical School, Boston. "These high-risk patients were treated less aggressively than others. Patients with higher baseline risk of adverse events who are more likely to derive the greatest benefit from aggressive interventions are among the least likely to receive them. These inverse relationships between treatment intensity and patient risk suggest opportunities for improvement."

According to the authors, under-treatment of the highest-risk patients may stem from concerns that the care provided could result in a negative event, such as bleeding from an antithrombotic agent, which could then be attributed to the provider. In contrast, an outcome such as death is perceived as being beyond the provider’s control. They highlight the need for broader application of risk stratification tools and the development of integrated assessment of different risks to individualize management decisions and improve outcomes.

Keywords: Cardiac Catheterization, Recombinant Proteins, Peptide Fragments, Ticlopidine, Fibrinolytic Agents, Hospitalization, Hirudins, United States, Platelet Glycoprotein GPIIb-IIIa Complex

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