Comparison with other studies
NSTEACS, heart failure, Myocardial Ischaemia, death
ACUTE CORONARY SYNDROMES, SECONDARY, MYOCARDIAL INFARCTIONS, ST ELEVATION MYOCARDIAL INFARCTION, HEART ATTACK, EVENTS, HEART FAILURE
International guidelines recommend the use of the GRS to stratify patients admitted to hospital with NSTEACS so that they receive evidence based care according to their estimated risk of future ischaemic events.The AGRIS trial found that for acute coronary syndromes including ST elevation myocardial infarction, the GRS increased the use of early invasive strategies, but not other aspects of care, for people at higher risk.We found that the receipt of drug treatments was high in both arms, likely reflecting the strong evidence base for their use. Similar findings were observed in the AGRIS trial, and it is possible that the potential to show changes in care with GRS was therefore reduced. For participants with a troponin positive blood test, the GRS seemed to relate to care intervention uptake, indicating that the GRS might have an effect on patients with higher risk NSTEACS. Equally, the GRS could have a longer term impact on the delivery of care and outcomes in NSTEACS, and this will be explored in a 24 month follow-up study.The number of coronary angiograms performed within 24 hours and 72 hours was low, possibly because physicians were uncertain about their effectiveness according to the evidence base despite recommendations for their use in international guidelines for risk stratification.National routine electronic records data showed that cardiovascular events at 12 months were higher than expected. These figures were driven by a high incidence of cardiovascular hospital admissions, and less so by cardiovascular deaths, non-fatal myocardial infarctions, and new onset heart failure. The low rates of new onset heart failure were possibly because of high routine use of secondary prevention drugs.
We acknowledge the potential limitations of the study. Although the use of electronic health records data offers an efficient and pragmatic method by which outcomes information might be studied, we did not adjudicate the trial endpoints and it is possible that there was misclassification of events.A strength of this randomised clinical trial is that all participants were followed up for admission to hospital and death using routine administrative data (including Hospital Episode Statistics and Office for National Statistics data), and the classification of their events was performed using ICD-10 codes. This strategy provides a potentially efficient mechanism through which randomised controlled trials might be delivered. Recruiting clusters were participating in the UK national heart attack register (Myocardial Ischaemia National Audit Project), and staff were therefore familiar with the study baseline variables.