Discordance between level of risk and intensity of evidence-based treatment in patients with acute coronary syndromes

Ian A Scott, Patrick H Derhy, Di O’Kane, Kylie A Lindsay, John J Atherton and Mark A Jones, for the CPIC Cardiac Collaborative
Med J Aust 2007; 187 (3): 153-159.


Objectives: To examine the relation between treatment intensity and level of risk in routine hospital care of patients with acute coronary syndromes (ACS), and to identify independent predictors of use or omission for each of eight evidence-based treatments.

Design: Retrospective cohort study of patients fulfilling case definition for ACS in whom absolute risk of adverse outcomes was quantified (as low, moderate, or high risk) using formal prediction rules, and for whom treatment eligibility was determined using expert-agreed criteria.

Participants and setting: 3912 consecutive or randomly selected patients admitted to 21 hospitals in Queensland, Australia between 1 August 2001 and 31 December 2005.

Results: The proportions of eligible patients receiving treatment varied inversely with risk level in regard to reperfusion therapies of fibrinolytic therapy or primary angioplasty (low risk, 88.3%; moderate risk, 61.9%; high risk, 18.2%; P < 0.001), heparin (91.4%; 83.7%; 72.8%; P < 0.001) and early invasive intervention (33.6%; 24.0%; 18.5%; P < 0.001). Significantly more low- and moderate- than high-risk patients received β-blockers (87.0%; 88.5%; 79.1%; P < 0.001), lipid-lowering agents (87.3%; 84.8%; 65.8%; P < 0.001), and referral to cardiac rehabilitation (51.8%; 46.0%; 34.4%; P < 0.001) at discharge. The most frequent independent predictors of treatment omission in all patients included increasing age (5 of 8 treatments), previous ACS or atrial tachyarrhythmias (4 of 8), and past history of cerebrovascular accident or congestive heart failure (3 of 8).

Conclusion: In routine care of ACS, eligible patients at high risk receive treatment less frequently than those at low and moderate risk. Reforms in professional education, routine use of risk stratification tools, guideline recommendations tailored to population-specific reductions in absolute risk, and better hospital networking with standardised triage and referral procedures for invasive procedures may help reduce selection bias in the delivery of indicated care.

  • Ian A Scott2
  • Patrick H Derhy3
  • Di O’Kane3
  • Kylie A Lindsay3
  • John J Atherton2,3
  • Mark A Jones1
  • for the CPIC Cardiac Collaborative

  • 1 Princess Alexandra Hospital, Brisbane, QLD.
  • 2 University of Queensland, Brisbane, QLD.
  • 3 Royal Brisbane and Women’s Hospital, Brisbane, QLD.


The members of the CPIC Cardiac Collaborative in addition to the authors are: Bundaberg Hospital: Dr Andre Conradie, Vivienne Tapiolas; Caboolture/Redcliffe Hospitals: Dr Robin Bradbear, Dr Peter Stride, Kylie Hillier; Cairns Hospital: Dr Prasad Challa, Yvonne Hodder, Karyn Greensill, Donna Kreuter; Gladstone Hospital: Dr Peter Durman, Julie McRae, Jacqui Bulbrook; Gold Coast Hospital: Dr Nick Buckmaster, Dr Greg Aroney, Vicky Syme; Hervey Bay Hospital: Marilyn Jensen; Ingham Hospital: Janine Johnson, Judy Cardillo; Innisfail Hospital: Majella van Tienan, Dr Peter McKenna; Ipswich Hospital: Dr Jane Hoare, Dr Mandeep Mathur, James Mitchell; Logan Hospital: Dr Jeffrey Franco, Katrina Chisholm; Maryborough Hospital: Dr Alan Jones, Kylie Lenthall; Mackay Hospital: Dr Belinda Weich, Lyn Gralow; Nambour Hospital: Dr Steven Coverdale, Megan Courtney; Princess Alexandra Hospital: Dr Paul Garrahy, Melodie Downey, Michelle Winning; Queen Elizabeth II Hospital: Dr Judy Flores; Royal Brisbane and Women’s Hospital: Dr John Atherton, Damien Otago; Redland Hospital: Dr David Henderson, Karen Pratt; Rockhampton Hospital: Dr Raj Shetty, Cara Edwards; Toowoomba Hospital: Dr Spencer Toombes, Caroline Leopold, Caroline Byrne; Townsville Hospital: Dr Raibhan Yadav, Leonie Jones.

Competing interests:

None identified.

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