| BackgroundAcute coronary syndrome(ACS) includes non-ST segment elevation acute coronary syndrome(NSTEACS) and ST segment elevation acute coronary syndrome(STEACS), which is namely ST segment elevation myocardial infarction(STEMI). NSTEACS consists of unstable angina(UA) and non-ST segment elevation myocardial infarction(NSTEMI), of which cardiac troponins is the differential points. The prevalence of NSTEACS, relative to STEMI, has been determined from multiple surveys and registries. Different from STEMI which major adverse events happens early in the illness, the cardiovascular risk of NSTEACS can last several days to months. Hospital mortality of patients with NSTEACS is very similar with and2times higher than those with STEMI at6months and4years. It’s essential to intensify both the acute and long-term management of patients with NSTEACS.Based on progress in clinical and pathophysiologic studies of ACS, European Society of Cardiology(ESC), American Heart Association(AHA), Chinese Medical Association of Cardiovascular Disease as well as other societies have been issued and updating Guidelines of NSTEACS in recent years, which greatly improve the diagnosis and treatment of patients with NSTEACS both in drug therapy and invasive strategy. It emphasizes the combination of available pharmacologic treatment and invasive revascularization, and choose optimal treatment according to clinical risk assessment so as to lighten ischemia while minimizing bleeding complications and prevent major adverse cardiac events(MACEs). Registry studies have examined that evidence based therapies(EBTs) can reduce the rates of MACEs, improve outcomes and living quality of patients with NSTEACS and cut down burden of disease. However, substantial variations exist in adherence to guidelines among different regions and countries. Despite this, most observational data suggest that treatment-eligible patients in the highest objective risk score categories and with high risk clinical characteristics(elderly, female, diabetes mellitus, chronic kidney disease, anemia etc.) are the least likely to receive EBTs, which is so called "risk-treatment paradox". Current situation in regards to EBT demonstrated measures applied in clinical practice is little studied at present.ObjectivesTo analyze the current implementary status of the guideline of Non-ST-segment Elevation Acute Coronary Syndrome (NSTEACS) in clinical practice, explore the gap between guideline recommendations and treatment measures applied in real-world and investigate the influencing factors.Methods1. We collected313patients with NSTEACS, and evaluated their therapeutic strategies during hospitalization retrospectively according to NSTEACS guidelines, including demographic and baseline characteristics, clinical features, diagnostic and therapeutic strategies, pharmacologic treatment during hospital and at discharge etc.2. Patients were stratified into three groups according to the TIMI risk score calculated on admission:low risk, intermediate risk, and high risk. We made subgroup analyses by risk stratification, sex, age and diabetes, anemia or chronic kidney disease or not.3. All available data were analyzed by SPSS17.0. The analysis methods included descriptive analysis, t-test, one-way analysis of variance or Kruskal-Wallis test, χ2or Fisher’s exact test and multivariable logistic regression analysis.Results1. Overall, use rate of invasive procedures was63.3%. The percentage of CAG, PCI and CABG were61.3%,42.2%and9.3%respectively. Early (<72h) invasive strategy was adopted in40.6%patients. Most of medicines designated as Class I recommendations by guidelines were reasonably used, and use rates of them were high with no "risk-treatment paradox". However, double dose of aspirin(12.1%), loading dose of clopidogrel (32.6%), GPI (15.7%) and ACEI/ARB (65.2%) were in low utilization. The course of anti-coagulation was up to standard recommended by guidelines in84.9%patients. The rate of OMT checked at discharge was39.0%. 2. High-risk patients and special population were much less likely to undergo various invasive procedures (all P<0.05). While, much more high risk score patients and patients with DM selected CABG than their counterparts with no significant difference (all P>0.05). ASA, anticoagulants, beta-blocker and statins were used similarly among different groups. Other antiplatelet therapies were prescribed much less in high risk group and special population with high risk characteristics to varying degree, while, CCB and/or ACEI/ARB were prescribed diametrically opposite in groups.3. The independent risk factors of (early) invasive strategy by multivariable logistic regression analysis were elderly (≥75y), diabetes and heart failure(all P <0.05). Multivariable logistic regression analysis showed that factors independently associated with double dose of ASA, loading dose of clopidogrel and ACEI/ARB usage were history of angina, hear failure and PCI respectively (all P<0.05). PCI and makers of myocardial injury were independent predictor of GPI uptake (all P<0.01). After adjusted baseline clinical characteristics, CABG (OR=11.497,95%CI:2.560-51.635, P=0.001) was independently associated with underuse of EBT at discharge.Conclusions1. The management of NSTEACS in our hospital is generally in accordance with guidelines, while, there are certainly some gaps existed in many aspects. It’s necessary to further dissemination and implementation of guidelines, so that patients with NSTEACS can gain optimal medical treatments.2. Special population with different high-risk characteristics are consistently less likely to receive invasive strategy and antiplatelet therapies in different modality. To get over the "risk-treatment paradox" is in desperate need. We must highlight the important role of risk stratification.3. High risk factors are associated with the underuse of EBT. Medication therapeutic may be influenced by patients’therapeutic strategy, and it’s necessary to enhance the management of patients with CABG... |
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