Contemporary management of acute coronary syndromes: does the practice match the evidence? The global registry of acute coronary events (GRACE)

Acute coronary syndromes (ACS) are a major cause of morbidity and mortality and constitute the largest medical indication for hospitalisation in the UK. ¹ Insights into the pathophysiology of ACS and evidence from trials of pharmacological and interventional (revascularisation) treatment have led to the update of guidelines in the UK, ² in Europe, ^{3, 4} and in the USA. ⁵ Previous surveys have indicated that British practice was not consistent with guidelines and in many cases did not match that of other European countries (ENACT (European network for acute coronary treatment), ⁶ PRAIS-UK (prospective registry of acute ischemic syndromes in the UK) ⁷ ). However, the extent to which such guidelines have been implemented in contemporary clinical practice in the UK is unknown.

Key elements from the current guidelines of the European Society of Cardiology recommend that patients with ST segment elevation or new left bundle branch block should be reperfused either by primary percutaneous coronary intervention (PCI) performed 90 minutes after the first medical contact or by thrombolysis within 30 minutes of presentation to hospital.).

Table 1 Summary of acute coronary syndrome guidelines applicable to British patients

*Published 2003; [dagger]published 2000; [double dagger]published 2001; §published 2002.
ACEI, angiotensin converting enzyme inhibitor; BCS, British Cardiac Society; ESC, European Society of Cardiology; GP, glycoprotein; LMWH, low molecular weight heparin; MI, myocardial infarction; NSF, National Service Framework; PCI, percutaneous coronary intervention.

ST elevation MI	Non-ST elevation MI/unstable angina
Treatment	BCS	ESC*	NSF[dagger]	Treatment	BCS[double dagger]	ESC§	NSF[dagger]
Initial	Aspirin, thrombolysis/ PCI	Aspirin, thrombolysis/PCI	Aspirin, thrombolysis	For low risk	Aspirin, LMWH, nitrates, β blockers	Aspirin, LMWH, nitrates, β blockers, clopidogrel	Aspirin, unfractionated heparin or LMWH, β blocker, nitrates
Subsequent	β Blocker	β Blocker, ACEI <24 hours	β Blocker, ACEI	For high risk	GP IIb/IIIa, angiogram (also intermediate risk)	GP IIb/IIIa, angiogram	Angiogram
On discharge	Aspirin, β blocker, statin	Aspirin (clopidogrel if aspirin contraindicated), β blocker, statin	Aspirin, β blocker, statin	On discharge	Aspirin, β blocker, statin	Aspirin, clopidogrel (for at least 9 months), β blocker, statin	Aspirin, β blocker, statin

The British Cardiac Society guideline for non-ST segment elevation ACS also stratifies patients into high, intermediate, and low risk groups.).

The National Service Framework (NSF) for coronary heart disease is a British government publication that aims to provide...