Guideline Recommended Therapies and Clinical Outcomes According to the Risk for Recurrent Cardiovascular Events after an Acute Coronary Syndrome

Introduction: Patients after an acute coronary syndrome (ACS) are at increased risk for recurrent cardiovascular (CV) events. Although guideline-recommended therapies reduce the rate of recurrent CV events, patients who are at increased risk are often paradoxically undertreated. The TIMI risk score for secondary prevention (TRS2^oP), a recently validated tool, incorporates 9 clinical risk-factors and stratifies patients by the risk for recurrent CV events after an ACS. We aimed to examine the management, clinical outcomes, and temporal trends of patients with ACS stratified by the TRS2^oP, and identify risk-groups who particularly might benefit from optimal therapy.

Methods: Included were patients with ACS enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2008-2016. Patients were stratified by the TRS 2^oP to low (score 0-1), intermediate (2), and high-risk (≥3). Clinical outcomes included 30d MACE (death, MI, stroke, unstable angina, stent thrombosis, urgent revascularization) and 1-year mortality.

Results: Of 6827 ACS patients enrolled, 35% were low-risk, 27% intermediate- risk and 38% high-risk. Compared with the other risk-groups, high-risk patients were older, more commonly women, had more renal dysfunction, heart failure, and a higher grace score (p<0.001 for each). High-risk patients were treated less commonly with guideline-recommended therapies during hospitalization (PCI) and at discharge (statins, DAPT, cardiac rehabilitation). High-risk patients had higher 30d MACE, 30d mortality and 1y mortality (1.7% low-risk, 4.6% intermediate-risk, and 16.1% high-risk; p<0.001). Over the last decade, utilization of guideline-recommended therapies has increased among all risk-groups (Table). However, the rate of 30d MACE and 1-year mortality has decreased among patients at high-risk, but not among patients at low and intermediate-risk (Table).

Conclusion: Despite an improvement in the management of high-risk ACS patients, they are still undertreated with guideline-recommended therapies. Nevertheless, the outcome of high-risk ACS patients has significantly improved in the last decade, thus they should not be denied these therapies.