Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands

Abstract

ObjectiveCardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS.DesignA web-based survey containing clinical vignettes.Setting and participantsRegistered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes ‘without’ a risk score present, while group 2 completed vignettes ‘with’ a risk score present.Results129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores.ConclusionsWhen deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.

Outcomes of non-invasive diagnostic modalities for the detection of coronary artery disease: network meta-analysis of diagnostic randomised controlled trials

“…This result could be attributed to the fact that doctors make the final decision to refer patients for further invasive testing on the basis of factors other than initial non-invasive imaging, such as clinical presentation, persistence of symptoms, repeated clinical encounters, and patient preference. 74 75 A functional testing strategy might provide important cost benefits, owing to fewer referrals for invasive coronary angiography and revascularisation and lower radiation and contrast agent exposure while resulting in similar clinical outcomes. 76 Such benefits could reduce healthcare expenditure in this common clinical scenario in appropriately selected patients with low risk acute coronary syndrome.…”

Management of acute coronary syndrome in emergency departments: a cross sectional multicenter study (Tunisia)

“…These times varied according to gender, age groups and ACS type. Appropriate identification of patients with symptoms of chest pain and early discharge as recommendations should be improved [ 21 – 24 ]. We explained the increasing duration between chest pain onset and emergency arrival with increasing age by the emergence of social loneliness of the elderly in Tunisia [ 11 , 14 ].…”

Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a ‘real world’ prospective registry

“…A possible explanation for this so-called ‘risk-paradox’ is that cardiologists have more safety concerns with early invasive treatment in older patients presenting with NSTE-ACS. Although invasive treatment is associated with significant benefits independent of age [ 23 – 25 ], age appeared to be underrated as a risk factor in deciding whether or not to perform angiography [ 26 , 27 ]. However, it is also possible that other valid reasons led to a reluctance to perform invasive procedures in older patients, such as functional status, patient’s preference and frailty, which has been shown to be related to a worse outcome in NSTE-ACS [ 28 ].…”