The risk-treatment paradox in acute coronary syndrome patients: insights from the FORCE-ACS registry
Authors: Azzahhafi J , Van Der Sangen N M R , Chan Pin Yin D R P P , Simao Henriques J P , Kikkert W J , Ten Berg J M ,   FORCE-ACS
Published: October 2021

Abstract

Background
Acute coronary syndrome (ACS) patients at high risk might benefit most from guideline-recommended interventions. However, it is well recognized that the delivery of guideline-directed care is inversely related to the estimated mortality risk, the so called risk-treatment paradox.

Purpose
To assess the existence of the risk-treatment paradox in a contemporary cohort of ACS patients and its possible association with one-year mortality.

Methods
The study population consisted patients enrolled in the FORCE-ACS registry who survived their initial admission. All ACS patients were stratified into low, intermediate or high mortality risk based on the Global Registry of Acute Coronary Events (GRACE) risk score. Optimal guideline-recommended care was defined as undergoing coronary angiography during initial hospital admission and receiving all outpatient medications with a class I guideline recommendation (i.e. aspirin, P2Y12-inhibitor, beta-blocker, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker and cholesterol-lowering drug). Aspirin and/or a P2Y12-inhibitor on top of an oral anticoagulant was also considered as optimal guideline-recommended care. The cumulative incidence of one-year mortality between optimal and suboptimal managed patients, within each GRACE risk score stratum, was estimated.

Results
In total, 2,524 patients who were enrolled between January 2015 and June 2018 were included. Based on the GRACE risk score, 46.9% of patients were classified as low-risk, 37.6% as intermediate-risk and 15.5% as high-risk. Overall, 49.8% of patients received optimal guideline-recommended care. Among the different risk strata, 54.9% of the low-risk, 49.1% of the intermediate-risk and 36.1% of the high-risk patients received optimal guideline-recommended care (Table 1).
DAPT or DAT treatment (95.3% overall) did not differ between the risk categories. Beta-blockers were prescribed less frequently (69.6% overall), butprescription rates did not differ between the risk categories. ACE-inhibitors/ARBs were prescribed in 74.1% of all patients, but less often in high risk patients. Cholesterol lowering-drugs were prescribed in almost all patients (94.9% overall), but less frequently in high risk patients. Overall, 93.9% of patients underwent coronary angiography (CAG), high-risk patients had a statistically significant lower likelihood of undergoing CAG. In all risk categories, optimal guideline-recommended care was associated with a lower one-year mortality as compared to sub-optimal treatment (5.7% vs. 15.6% in high-risk) (Fig. 1).

Conclusion
Patients at higher estimated mortality risk, based on the GRACE-risk score, are less likely to receive guideline-recommended care. Although, the absolute benefit from guideline-recommended care appears to be greater in high-risk patients. Receiving guideline-recommended care was associated with a statistically significant better prognosis in intermediate- and high-risk patients.

Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW Netherlands TopZorgSt. Antonius Research funds Figure 1. All-cause mortality