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

Ingo Ahrens, Oleg Averkov, Eduardo C. Zúñiga, Alan Y.Y. Fong, Khalid F. Alhabib, Sigrun Halvorsen, Muhamad A.B.S.K. Abdul Kader, Ricardo Sanz-Ruiz, Robert Welsh, Hongbin Yan, Phil Aylward

Research output: Contribution to journalReview article

Abstract

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.

LanguageEnglish
JournalClinical Cardiology
DOIs
Publication statusPublished - 1 Jan 2019

Keywords

  • antiplatelet therapy
  • early invasive strategy
  • non-ST-segment elevation myocardial infarction
  • treatment-risk paradox

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this

Ahrens, Ingo ; Averkov, Oleg ; Zúñiga, Eduardo C. ; Fong, Alan Y.Y. ; Alhabib, Khalid F. ; Halvorsen, Sigrun ; Abdul Kader, Muhamad A.B.S.K. ; Sanz-Ruiz, Ricardo ; Welsh, Robert ; Yan, Hongbin ; Aylward, Phil. / Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction : Understanding and addressing the global risk-treatment paradox. In: Clinical Cardiology. 2019.
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abstract = "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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author = "Ingo Ahrens and Oleg Averkov and Z{\'u}{\~n}iga, {Eduardo C.} and Fong, {Alan Y.Y.} and Alhabib, {Khalid F.} and Sigrun Halvorsen and {Abdul Kader}, {Muhamad A.B.S.K.} and Ricardo Sanz-Ruiz and Robert Welsh and Hongbin Yan and Phil Aylward",
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Ahrens, I, Averkov, O, Zúñiga, EC, Fong, AYY, Alhabib, KF, Halvorsen, S, Abdul Kader, MABSK, Sanz-Ruiz, R, Welsh, R, Yan, H & Aylward, P 2019, 'Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox', Clinical Cardiology. https://doi.org/10.1002/clc.23232

Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction : Understanding and addressing the global risk-treatment paradox. / Ahrens, Ingo; Averkov, Oleg; Zúñiga, Eduardo C.; Fong, Alan Y.Y.; Alhabib, Khalid F.; Halvorsen, Sigrun; Abdul Kader, Muhamad A.B.S.K.; Sanz-Ruiz, Ricardo; Welsh, Robert; Yan, Hongbin; Aylward, Phil.

In: Clinical Cardiology, 01.01.2019.

Research output: Contribution to journalReview article

TY - JOUR

T1 - Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction

T2 - Clinical Cardiology

AU - Ahrens, Ingo

AU - Averkov, Oleg

AU - Zúñiga, Eduardo C.

AU - Fong, Alan Y.Y.

AU - Alhabib, Khalid F.

AU - Halvorsen, Sigrun

AU - Abdul Kader, Muhamad A.B.S.K.

AU - Sanz-Ruiz, Ricardo

AU - Welsh, Robert

AU - Yan, Hongbin

AU - Aylward, Phil

PY - 2019/1/1

Y1 - 2019/1/1

N2 - 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.

AB - 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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KW - early invasive strategy

KW - non-ST-segment elevation myocardial infarction

KW - treatment-risk paradox

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