European Heart Journal Advance Access originally published online on April 17, 2007
European Heart Journal 2007 28(9):1045-1046; doi:10.1093/eurheartj/ehm084
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Barriers to clinical risk scores adoption
Dipartimento di Medicina Interna, Cardioangiologia, Epatologia (Padiglione 11), University of Bologna, Via Massarenti 9, 40138 Bologna, Italy
* Corresponding author. Tel:/fax: +39 (0) 513 47290. E-mail address: raffaele.bugiardini{at}unibo.it
This editorial refers to ‘Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better’
by A.T. Yan et al., on page 1072
Variability in physician decision-making is evident from recent studies on acute coronary syndrome documenting substantial differences in the use of various cardiac procedures.1 Fundamental to decision-making is the recognition of the most powerful predictors of survival. It is essential for the cardiovascular specialists to attempt and define the appropriate indications for medications and procedures and to base these recommendations on data from clinical research studies whenever possible.
The essential feature of clinical judgment is that physicians do not act solely on an evidence basis or on an arbitrary basis. Clinical judgment combines personal clinical experience, published research, patient perspectives, and other insights. Clinical judgment, however, might be a flaw. Common elements that may produce errors include conflicting information, limited time, and the physicians' remind of their own clinical experience, the latter being too heavily influenced by recent cases or particularly bad or good outcomes.2 Clinical consensus guidelines are developed to overcome these recognized limitations by providing a complete and unbiased picture of published research and clinical experience.3,4
Guidelines in clinical practice
Although applying guidelines is highly rational, clinicians do not always make decisions in this fashion. The perspective article by Yan et al.5 is a welcome explication of this contentious topic. In this study, participating physicians were asked to categorize their patients into low, intermediate, and high-risk groups, according to the Canadian guidelines that are similar to the ACC/AHA and ESC guidelines. Cardiac catheterization is recommended for patients at high-risk. Nevertheless, approximately 30% of patients categorized as high risk did not undergo angiography. It follows that generating a guideline is no guarantee of its being widely adopted, even if doctors are purposely instructed to do so by protocol. Examining the barriers to their performance may provide insight into strategies for effective new future guideline implementations.
Physicians may find the information promoted in support of the recommended guidelines unconvincing. This is especially common when there is conflicting information. The development of risk scores gives a good example of this complexity. During the past decade, many colleagues have been exploring the potential of the use of some risk prediction rules based on integrated simple clinical variables. The current study5 developed three hypothetical scenarios representing patients as objectively stratified by the Thrombolysis in Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy (PURSUIT), and Global Registry of Acute Cardiac Events (GRACE) risk scores, and determined how often these ‘patients’ were referred for cardiac catheterization and their outcomes. The focus on the comparative performance of these scores may have obscured a remarkable finding: overall, patients stratified by the TIMI, PURSUIT, and GRACE risk scores as high-risk were approximately 20% less likely to be referred for cardiac catheterization when compared with patients classified as high-risk by their physicians using recommendations from clinical guidelines. However, should be noted that all of these risk scores conferred greater prognostic information when compared with physicians' risk assessment. Physicians might, therefore, interpret the article in the journal meaning that clinical guidelines recommendations are not truly representing a significant change for the better. At the moment, just how effective the use of clinical guidelines can be on care is poorly established.6 Conflicting and/or insufficient information results in a reinforcement of the ‘status quo’: many physicians apply rules based on their personal experience.
Clinical risk scores may run counter to established rules
‘A patient with three-vessel coronary artery disease and left ventricular systolic dysfunction should have coronary revascularization’. This particular heuristic is generally accepted, but others are more controversial. For instance, patients who are found to have normal or only slightly narrowed coronary arteries on their angiographic study represent an unsolved problem, even in this era with focus on vulnerable patients.7 Not all physicians believe that lesions < 50% at angiography represent disease capable of explaining coronary events and warranting secondary prevention. Although a comprehensive review of this perplexing variance is beyond the scope of this article, it should be noted that risk scores have been calculated in the entire cohort of patients with acute coronary syndrome without any distinction between obstructive and non-obstructive coronary disease. In addition, most risk scores incorporate many variables, but did not include angiographic findings, and few studies have attempted to elucidate the links between specific clinical risk scores and underlying coronary anatomy. Given these uncertainties, many questions remain unanswered. Would a high-risk patient based on the calculated risk score be deemed to be at low risk because he/she presents non-obstructive lesions? And if so, is intensive medical therapy for acute coronary syndrome to be given? The general undertreatment of this subgroup of patients, which some authors found, is open to discussion.8 The absence of clear answers to these questions raises the possibility of serious disparities in the health care of acute coronary syndrome, especially in women who often show non-obstructive lesions. Clinical risk scores should be tested separately in patients with and without obstructive lesions, which may shed light on these issues.
Clinical value of the risk scores in patients without obstructive lesions
Recent work9 found that the 1-year death and myocardial infarction rate of patients with acute coronary syndrome, but without obstructive coronary artery disease is 2.1%. When the TIMI risk score was applied, the risk raised from 0.6% (TIMI score of 1) to 4.1% (TIMI score of 4 or more). The 0.6% death or myocardial infarction rate, seen with a TIMI score of 1, is the expected rate in the general population of low-risk asymptomatic subjects. Conversely, an event rate of 4.1% at 1-year is comparable with what it can be seen in many patients with acute coronary syndrome and obstructive lesions. These data reinforce the idea that non-obstructive coronary artery disease is a rather heterogeneous population. These patients may have a wide spectrum of risk for cardiac ischaemic events, and they need methods of risk stratification.10
As with any important clinical investigation, the study of Yan et al.5 generates additional questions. Ultimately, the clinical value of risk scores stems from the extent to which they are useful for addressing invasive management (referral to cardiac catheterization) and treatment (use of evidence-based medications). However, few studies have evaluated the application of clinical risk scores in guiding the appropriate selection of patients for whom invasive interventions are likely to be beneficial. Also, clinical guidelines give limited discretion in using the current range of medical treatment options: aspirin, statins, and anti-ischaemic drugs should be offered to all patients, irrespective of the predicted level of risk. Future work should, therefore, be addressed in promoting and validating the use of clinical risk scores into standardized ‘critical pathways.’ Most importantly, no controlled study has shown improvements in patient outcome if using clinical risk scores.
Approaches that enhance adoption of risk scores
Although barriers to clinical risk scores adoption are great, they are not insurmountable.
The article by Yan et al.5 highlights the need to clarify guideline recommendations and to develop prospective protocols for an effective risk assessment of acute coronary syndrome. Partnerships among providers, healthcare organizations, and researchers would be able to generate novel guideline structures and implementation strategies that have the potential to further improve patient care.
Conflict of interest: none declared.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.
doi:10.1093/eurheartj/ehm004 
References
- Fox KA, Goodman SG, Anderson FA Jr, Granger CB, Moscucci M, Flather MD, Spencer F, Budaj A, Dabbous OH, Gore JM, GRACE Investigators. From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes. The Global Registry of Acute Coronary Events (GRACE). Eur Heart J (2003) 24:1414–1424.
[Abstract/Free Full Text] - Eddy OM. Variations in physician practice: the role of uncertainty. Health Aff (1984) 3:74–89.[CrossRef][Medline]
- Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE III, Steward DE, Theroux P, Gibbons RJ, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Smith SC Jr. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardialminfarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients with Unstable Angina). Circulation (2002) 106:1883–1890.
[Free Full Text] - Bertrand ME, Simoons ML, Fox KA, Wallentin LC, Hamm CW, McFadden E, De Feyter PJ, Specchia G, Ruzyllo W. Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J (2002) 23:1809–1840.
[Free Full Text] - Yan AT, Yan RT, Tan M, Casanova A, Labinaz M, Sridhar K, Fitchett DH, Langer A, Goodman SG. Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better. Eur Heart J. doi:10.1093/ eurheartj/ehm004.
- Reilly BM, Evans AT, Schaider JJ, Das K, Calvin JE, Moran LA, Roberts RR, Martinez E. Impact of a clinical decision rule on hospital triage of patients with suspected acute cardiac ischemia in the emergency department. JAMA (2002) 288:342–350.
[Abstract/Free Full Text] - Bugiardini R, Bairey Merz CN. Angina with ‘normal’ coronary arteries: a changing philosophy. JAMA (2005) 293:477–484.
[Abstract/Free Full Text] - Patel MR, Chen AY, Peterson ED, Newby LK, Pollack CV Jr, Brindis RG, Gibson CM, Kleiman NS, Saucedo JF, Bhatt DL, Gibler WB, Ohman EM, Harrington RA, Roe MT. Prevalence, predictors, and outcomes of patients with non-ST-segment elevation myocardial infarction and insignificant coronary artery disease: results from the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE) initiative. Am Heart J (2006) 152:641–647.[CrossRef][ISI][Medline]
- Bugiardini R, Manfrini O, De Ferrari GM. Unanswered questions for management of acute coronary syndrome: risk stratification of patients with minimal disease or normal findings on coronary angiography. Arch Intern Med (2006) 166:1391–1395.
[Abstract/Free Full Text] - Bugiardini R, Badimon L, Collins P, Erbel R, Fox K, Hamm C, Pinto F, Rosengren A, Stefanadis C, Wallentin L, Van de Werf F. Angina, ‘normal’ coronary angiography, and vascular dysfunction: risk assessment strategies. PLoS Med (2007) 4:e12.[CrossRef][Medline]
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Related articles in EHJ:
- Risk scores for risk stratification in acute coronary syndromes: useful but simpler is not necessarily better
- Andrew T. Yan, Raymond T. Yan, Mary Tan, Amparo Casanova, Marino Labinaz, Kumar Sridhar, David H. Fitchett, Anatoly Langer, and Shaun G. Goodman
EHJ 2007 28: 1072-1078.[Abstract] [Full Text]
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