Matters arising

Cardiovascular diseases
Volume 193 - Issue 9

Acute coronary syndromes: consensus recommendations for translating knowledge into action

Author:  Richard W Harper

Med J Aust 2010; 193 (9): 550-553. || doi: 10.5694/j.1326-5377.2010.tb04048.x
Published online: 1 November 2010
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To the Editor: Recent articles in the Journal by Forge1 and Thompson2 expressing contradictory opinions on the management of patients with non-ST-elevation acute coronary syndromes (NSTEACS) highlight the difficulties in formulating guidelines for this condition.

Thompson argues that the routine invasive approach for patients with high-risk NSTEACS recommended by the National Heart Foundation of Australia (NHFA) guidelines is preferable to the selective invasive approach advocated by Forge.

In arguing his case, Forge relies on the results of the ICTUS (Invasive versus Conservative Treatment in Unstable Coronary Syndromes) trial,3 which showed no advantage for the routine invasive approach.

Unlike Forge, Thompson believes the ICTUS trial is of limited relevance. In part, he bases this contention on the fact that the 1-year mortality in the ICTUS study was 2.5% compared with 10.5% among Australian patients with non-ST elevation myocardial infarction, indicating that participants in the ICTUS trial were not high-risk patients.

This part of his argument is flawed. All patients who entered the ICTUS trial had elevated troponin levels, which according to NHFA guidelines automatically places them in a high-risk category that requires routine angiography. A more likely explanation for the mortality differences is that patients in the ICTUS trial either received better care, or were more compliant with their medical treatment than their Australian counterparts.

Thompson rightly argues that the ICTUS trial is but one study comprising “just over 10% of the evidence base” and that the totality of the data favours a routine invasive approach. Conversely, Forge contends that the ICTUS trial is the most contemporary of the studies and the one in which medical treatment most closely concurs with current best practice. Therefore, he argues, the results of this study should take precedence.

Faced with these conflicting viewpoints, writers of guidelines have an onerous task, particularly when compliance with guidelines may be used by bureaucrats and administrators to judge physician performance.

With respect to the NHFA guidelines for NSTEACS, a case can be made for more flexibility. For example, is it necessary to transfer all stable patients with NSTEACS and borderline troponin elevations from rural hospitals to metropolitan hospitals for angiography even when they may wait many days for such a transfer to occur? Ensuring that such patients receive, and are compliant with, optimal cardioprotective medications would be a greater gain. Guidelines are a valuable aid to clinical practice; they are not necessarily the overriding factor.

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