Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndromes

Chew, Derek P.; Ge, Junbo; Parsonage, William; Kerkar, Prafulla; Sulimov, V. A.; Horsfall, Matthew; Mattchoss, Sue

doi:10.1161/circoutcomes.111.000072

Cited by 62 publications

(34 citation statements)

References 36 publications

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“…13,15 Objective risk assessment using the GRACE risk score provided superior risk discrimination to physician-perceived risk for 6-month mortality in patients with ACS in the Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT) study. 49 Here, physicians were shown to overestimate the risk of 6-month mortality among patients with a low GRACE score and underestimate risk among those with a high GRACE score, consistent with the treatment-risk paradox. 49 Patients with NSTEMI at high ischemic risk were also not treated optimally in the Myocardial Ischaemia National Audit Project (MINAP) registry, in which the use of guideline-indicated care for patients with NSTEMI decreased with increasing GRACE risk score, even though optimal guideline-indicated care was associated with greater survival gains for high-risk patients.…”

Section: Patient Characteristicssupporting

confidence: 60%

“…Objective risk assessment using the GRACE risk score provided superior risk discrimination to physician‐perceived risk for 6‐month mortality in patients with ACS in the Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndrome Patients (PREDICT) study . Here, physicians were shown to overestimate the risk of 6‐month mortality among patients with a low GRACE score and underestimate risk among those with a high GRACE score, consistent with the treatment‐risk paradox …”

Section: Challenges For the Treatment Of Patients With Nstemimentioning

confidence: 52%

“…The risk may be underestimated by physicians based on the intensity of treatment the patients are receiving and the advanced age of the patient, despite evidence that an early intensive strategy in the eldest patients with NSTEMI is associated with the greatest reduction in 1‐year mortality . Physicians' and/or patients' concerns about the risk of complications with an invasive strategy may also affect the implementation of guideline‐indicated treatment.…”

Section: Challenges For the Treatment Of Patients With Nstemimentioning

confidence: 99%

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Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Ahrens

Zúñiga

et al. 2019

Clinical Cardiology

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Clinical guidelines for the treatment of patients with non‐ST‐segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long‐term mortality risk than patients with ST‐segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the “treatment‐risk paradox”). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four “P” factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long‐term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.

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Section: Patient Characteristicssupporting

confidence: 60%

Section: Challenges For the Treatment Of Patients With Nstemimentioning

confidence: 52%

Section: Challenges For the Treatment Of Patients With Nstemimentioning

confidence: 99%

See 1 more Smart Citation

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Ahrens

Zúñiga

et al. 2019

Clinical Cardiology

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“…In fact, comparative studies of the two approaches have consistently suggested greater overall accuracy when clinicians rely on actuarial information over anecdotal evidence in treatment decisions. 33–35 Kahneman, the Noble Prize-winning psychologist, describes decision-making as being comprised of 2 systems, a fast-thinking, intuitive system that rapidly makes decisions based on associations with past experiences, and a slow-working, logical, reasoning system that incorporates evidence to make a more rational decision. 36 The first, fast-thinking system is much easier and less stressful to use and is vastly preferred over the more deliberate second system.…”

Section: Discussionmentioning

confidence: 99%

Understanding physician-level barriers to the use of individualized risk estimates in percutaneous coronary intervention

Decker

Garavalia

et al. 2016

American Heart Journal

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Background The foundation of precision medicine is the ability to tailor therapy based upon the expected risks and benefits of treatment for each individual patient. In a prior study, we implemented a software platform, ePRISM, to execute validated risk-stratification models for patients undergoing percutaneous coronary intervention and found substantial variability in the use of the personalized estimates to tailor care. A better understanding of physicians’ perspectives about the use of individualized risk-estimates is needed to overcome barriers to their adoption. Methods In a qualitative research study, we conducted interviews, in-person or by telephone, with 27 physicians at 8 centers that used ePRISM until thematic saturation occurred. Data were coded using descriptive content analyses. Results Three major themes emerged amongst physicians who did not use ePRISM to support decisions-making: 1) “Experience versus Evidence,” physicians’ preference to rely upon personal experience and subjective assessments rather than objective risk estimates; 2) “Omission of Therapy,” the perception that the use of risk models leads to unacceptable omission of potentially beneficial therapy; and 3) ”Unnecessary Information,” the opinion that information derived from risk models is not needed because physicians’ decision-making is already sound and they already know the information. Conclusions Barriers to the use of risk models in clinical practice include physicians’ perceptions that their experience is sufficient, that models may lead to omission of therapy in patients that may benefit from therapy, and that they already provide good care. Anticipating and overcoming these barriers may improve the adoption of precision medicine.

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“…Risk models are an important part of AMI care because clinicians may underestimate the risk of adverse clinical outcomes when relying on implicit risk assessments alone, particularly in older adults. 6–8 …”

Section: Introduction1mentioning

confidence: 99%

Physicians' perceptions of the Thrombolysis in Myocardial Infarction (TIMI) risk score in older adults with acute myocardial infarction

et al. 2015

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Objectives To evaluate physician-perceived strengths and limitations of the Thrombolysis In Myocardial Infarction (TIMI) risk scores for use in older adults with acute myocardial infarction (AMI). Background The TIMI risk scores are risk stratification models developed to estimate mortality risk for patients hospitalized for AMI. However, these models were developed and validated in cohorts underrepresenting older adults (≥75 years). Methods Qualitative study using semi-structured telephone interviews and the constant comparative method for analysis. Results Twenty-two physicians completed interviews ranging 10–30 minutes (mean = 18 minutes). Median sample age was 37 years, with a median of 11.5 years of clinical experience. TIMI strengths included familiarity, ease of use, and validation. Limitations included a lack of risk factors relevant to older adults and model scope and influence. Conclusions Physicians report that the TIMI models, while widely used in clinical practice, have limitations when applied to older adults. New risk models are needed to guide AMI treatment in this population.

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Perceived Risk of Ischemic and Bleeding Events in Acute Coronary Syndromes

Cited by 62 publications

References 36 publications

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

Understanding physician-level barriers to the use of individualized risk estimates in percutaneous coronary intervention

Physicians' perceptions of the Thrombolysis in Myocardial Infarction (TIMI) risk score in older adults with acute myocardial infarction

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