{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,2]],"date-time":"2026-03-02T05:45:22Z","timestamp":1772430322812,"version":"3.50.1"},"reference-count":26,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2021,9,26]],"date-time":"2021-09-26T00:00:00Z","timestamp":1632614400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2021,9,26]],"date-time":"2021-09-26T00:00:00Z","timestamp":1632614400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["BMC Health Serv Res"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Background<\/jats:title>\n                <jats:p>Risk stratification is the cornerstone in managing patients with Non-ST Elevation Acute Coronary Syndromes (NSTE-ACS) and can attenuate the unjustified variability in treatment and guide the intervention decision notwithstanding its impact on better healthcare resources use. This study sought to disclose real adherence to guidelines in risk stratification of NSTE-ACS patients and in adopting intervention decision in practice.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>Multicentre prospective study recruited NSTE-ACS patients. Baseline characteristics were collected, TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores were calculated, management strategy as well as timing to intervention were recorded.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p><jats:italic>n.<\/jats:italic>\u2009=\u2009150, 72% of them were males, mean age was (59\u2009\u00b1\u200912.32) years. TIMI score was calculated in 5.3% of patients with none of them had GRACE score calculated. Invasive strategy was adopted in 85.24 and 82.7% of low GRACE and TIMI risk categories respectively, while invasive approach used in 42.85 and 40% of high GRACE and TIMI risk categories respectively. The immediate intervention in less than 2 hours was more to be used in low-risk categories while the high-risk and very high-risk patients whom were managed invasively were catheterized within &gt;72\u2009h; or more frequently to be non-catheterized at all. Sixty percent of those with acute heart failure, 80.76% of those with ongoing chest pain, 85% of those with dynamic ST changes same as 80% of those with cardiogenic shock were treated conservatively. Using multivariable analysis older age, ongoing chest pain and cardiogenic shock predicted conservative approach.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusions<\/jats:title>\n                <jats:p>There is striking underuse of risk scores in practice that can contribute to treatment-risk paradox in managing NSTE-ACS in form of depriving those with higher risk from invasive strategy despite being the most beneficiaries. The paradox did not only involve the very high-risk patients but also the very high-risk criteria like ongoing chest pain and cardiogenic shock predicted conservative approach, this highlights that the entire approach to patients with NSTE-ACS should be reconsidered, regardless of the use of risk scores in clinical practice. Audit programs activation in middle eastern countries can inform policymakers to put a limit to the treatment-risk paradox for better cardiovascular care and outcomes.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1186\/s12913-021-07034-7","type":"journal-article","created":{"date-parts":[[2021,9,26]],"date-time":"2021-09-26T20:04:40Z","timestamp":1632686680000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq"],"prefix":"10.1186","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7102-522X","authenticated-orcid":false,"given":"Zainab Atiyah","family":"Dakhil","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Hasan Ali","family":"Farhan","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2021,9,26]]},"reference":[{"key":"7034_CR1","unstructured":"Iraq coronary heart disease [Internet]. Data source: WHO 2017. Cited last February 2019. Available from https:\/\/www.worldlifeexpectancy.com\/iraq-coronary-heart-disease."},{"issue":"3","key":"7034_CR2","doi-asserted-by":"publisher","first-page":"464","DOI":"10.1007\/s11239-015-1227-1","volume":"41","author":"M Cohen","year":"2016","unstructured":"Cohen M. Long-term outcomes in high-risk patients with non-ST-segment elevation myocardial infarction. J Thromb Thrombolysis. 2016;41(3):464\u201374. https:\/\/doi.org\/10.1007\/s11239-015-1227-1.","journal-title":"J Thromb Thrombolysis"},{"issue":"4","key":"7034_CR3","doi-asserted-by":"publisher","first-page":"372","DOI":"10.1001\/archinternmed.2008.563","volume":"169","author":"AT Yan","year":"2009","unstructured":"Yan AT, Yan RT, Huynh T, Casanova A, Raimondo FE, Fitchett DH, et al. Understanding physicians' risk stratification of acute coronary syndromes: insights from the Canadian ACS 2 registry. Arch Intern Med. 2009;169(4):372\u20138. https:\/\/doi.org\/10.1001\/archinternmed.2008.563.","journal-title":"Arch Intern Med"},{"issue":"11","key":"7034_CR4","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2015-008523","volume":"5","author":"J Engel","year":"2015","unstructured":"Engel J, van der Wulp I, de Bruijne M, Wagner C. A cross-sectional multicentre study of cardiac risk score use in the management of unstable angina and non-ST-elevation myocardial infarction. BMJ Open. 2015;5(11):e008523. https:\/\/doi.org\/10.1136\/bmjopen-2015-008523.","journal-title":"BMJ Open"},{"issue":"2","key":"7034_CR5","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1093\/eurheartj\/ehy394","volume":"40","author":"FJ Neumann","year":"2018","unstructured":"Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, et al. 2018 ESC\/EACTS guidelines on myocardial revascularization. Eur Heart J. 2018;40(2):87\u2013165.","journal-title":"Eur Heart J"},{"issue":"3","key":"7034_CR6","doi-asserted-by":"publisher","first-page":"181","DOI":"10.1007\/s12471-016-0939-y","volume":"25","author":"P Damman","year":"2017","unstructured":"Damman P, van\u2019t Hof AW, Ten Berg JM, Jukema JW, Appelman Y, Liem AH, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: comments from the Dutch ACS working group. Neth Hear J. 2017;25(3):181\u20135. https:\/\/doi.org\/10.1007\/s12471-016-0939-y.","journal-title":"Neth Hear J"},{"key":"7034_CR7","doi-asserted-by":"publisher","first-page":"29A","DOI":"10.1016\/S0828-282X(09)71051-7","volume":"25","author":"ML Knudtson","year":"2009","unstructured":"Knudtson ML, Norris CM, Galbraith PD, Hubacek J, Ghali WA. Explicit risk in acute coronary syndrome management. Can J Cardiol. 2009;25:29A\u201336A. https:\/\/doi.org\/10.1016\/S0828-282X(09)71051-7.","journal-title":"Can J Cardiol"},{"issue":"10","key":"7034_CR8","doi-asserted-by":"publisher","first-page":"825","DOI":"10.1016\/j.jacc.2008.11.034","volume":"53","author":"FS Resnic","year":"2009","unstructured":"Resnic FS, Welt FG. The public health hazards of risk avoidance associated with public reporting of risk-adjusted outcomes in coronary intervention. J Am Coll Cardiol. 2009;53(10):825\u201330. https:\/\/doi.org\/10.1016\/j.jacc.2008.11.034.","journal-title":"J Am Coll Cardiol"},{"issue":"1","key":"7034_CR9","doi-asserted-by":"publisher","first-page":"418","DOI":"10.1186\/1472-6963-14-418","volume":"14","author":"J Engel","year":"2014","unstructured":"Engel J, Heeren MJ, van der Wulp I, de Bruijne MC, Wagner C. Understanding factors that influence the use of risk scoring instruments in the management of patients with unstable angina or non-ST-elevation myocardial infarction in the Netherlands: a qualitative study of health care practitioners\u2019 perceptions. BMC Health Serv Res. 2014;14(1):418. https:\/\/doi.org\/10.1186\/1472-6963-14-418.","journal-title":"BMC Health Serv Res"},{"issue":"10","key":"7034_CR10","doi-asserted-by":"publisher","first-page":"1019","DOI":"10.1001\/archinte.167.10.1019","volume":"167","author":"FA McAlister","year":"2007","unstructured":"McAlister FA, Oreopoulos A, Norris CM, Graham MM, Tsuyuki RT, Knudtson M, et al. Exploring the treatment-risk paradox in coronary disease. Arch Intern Med. 2007;167(10):1019\u201325. https:\/\/doi.org\/10.1001\/archinte.167.10.1019.","journal-title":"Arch Intern Med"},{"key":"7034_CR11","doi-asserted-by":"crossref","unstructured":"Shuster JJ. CRC handbook of sample size guidelines for clinical trials: CRC Press; 2019. p. 1\u2013862.","DOI":"10.1201\/9781315150864-1"},{"issue":"1","key":"7034_CR12","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1186\/s43044-021-00155-8","volume":"73","author":"ZA Dakhil","year":"2021","unstructured":"Dakhil ZA, Farhan HA. Non-ST elevation acute coronary syndromes; clinical landscape, management strategy and in-hospital outcomes: an age perspective. Egypt Heart J. 2021;73(1):33. https:\/\/doi.org\/10.1186\/s43044-021-00155-8.","journal-title":"Egypt Heart J"},{"issue":"16","key":"7034_CR13","doi-asserted-by":"publisher","first-page":"1912","DOI":"10.1001\/jama.295.16.1912","volume":"295","author":"ED Peterson","year":"2006","unstructured":"Peterson ED, Roe MT, Mulgund J, DeLong ER, Lytle BL, Brindis RG, et al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. Jama. 2006;295(16):1912\u201320. https:\/\/doi.org\/10.1001\/jama.295.16.1912.","journal-title":"Jama."},{"issue":"6","key":"7034_CR14","doi-asserted-by":"publisher","first-page":"1108","DOI":"10.1016\/j.ahj.2007.07.040","volume":"154","author":"AT Yan","year":"2007","unstructured":"Yan AT, Yan RT, Tan M, Huynh T, Soghrati K, Brunner LJ, et al. Registries investigators. Optimal medical therapy at discharge in patients with acute coronary syndromes: temporal changes, characteristics, and 1-year outcome. Am Heart J. 2007;154(6):1108\u201315. https:\/\/doi.org\/10.1016\/j.ahj.2007.07.040.","journal-title":"Am Heart J"},{"key":"7034_CR15","doi-asserted-by":"publisher","unstructured":"Badings EA, Hermanides RS, Van Der Sluis A, Dambrink JH, Gosselink AT, Kedhi E, et al. Use, timing and outcome of coronary angiography in patients with high-risk non-ST-segment elevation acute coronary syndrome in daily clinical practice: insights from a \u2018real world\u2019prospective registry. Netherlands Heart Journal. 2019;27(2):73\u201380. https:\/\/doi.org\/10.1007\/s12471-018-1212-3.","DOI":"10.1007\/s12471-018-1212-3"},{"issue":"9","key":"7034_CR16","doi-asserted-by":"publisher","first-page":"865","DOI":"10.1093\/eurheartj\/ehi187","volume":"26","author":"GP de Ara\u00fajo","year":"2005","unstructured":"de Ara\u00fajo GP, Ferreira J, Aguiar C, Seabra-Gomes R. TIMI, PURSUIT, and GRACE risk scores: sustained prognostic value and interaction with revascularization in NSTE-ACS. Eur Heart J. 2005;26(9):865\u201372. https:\/\/doi.org\/10.1093\/eurheartj\/ehi187.","journal-title":"Eur Heart J"},{"issue":"24","key":"7034_CR17","doi-asserted-by":"publisher","first-page":"e139","DOI":"10.1016\/j.jacc.2014.09.017","volume":"64","author":"EA Amsterdam","year":"2014","unstructured":"Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al. 2014 AHA\/ACC guideline for the management of patients with non\u2013ST-elevation acute coronary syndromes: a report of the American College of Cardiology\/American Heart Association task force on practice guidelines. J Am Coll Cardiol. 2014;64(24):e139\u2013228. https:\/\/doi.org\/10.1016\/j.jacc.2014.09.017.","journal-title":"J Am Coll Cardiol"},{"issue":"3","key":"7034_CR18","doi-asserted-by":"publisher","first-page":"267","DOI":"10.1093\/eurheartj\/ehv320","volume":"37","author":"M Roffi","year":"2016","unstructured":"Roffi M, Patrono C, Collet JP, Mueller C, Valgimigli M, Andreotti F, et al. 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent STsegment elevation: task force for the Management of Acute Coronary Syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2016;37(3):267\u2013315. https:\/\/doi.org\/10.1093\/eurheartj\/ehv320.","journal-title":"Eur Heart J"},{"key":"7034_CR19","doi-asserted-by":"publisher","first-page":"26","DOI":"10.1016\/j.ijcard.2018.08.015","volume":"272","author":"A Saar","year":"2018","unstructured":"Saar A, Marandi T, Ainla T, Fischer K, Bl\u00f6ndal M, Eha J. The risk-treatment paradox in non-ST-elevation myocardial infarction patients according to their estimated GRACE risk. Int J Cardiol. 2018;272:26\u201332. https:\/\/doi.org\/10.1016\/j.ijcard.2018.08.015.","journal-title":"Int J Cardiol"},{"issue":"8","key":"7034_CR20","doi-asserted-by":"publisher","first-page":"744","DOI":"10.1177\/0003319710369794","volume":"61","author":"P Panduranga","year":"2010","unstructured":"Panduranga P, Sulaiman K, Al-Zakwani I, Zubaid M, Rashed W, Al-Mahmeed W, et al. Utilization and determinants of in-hospital cardiac catheterization in patients with acute coronary syndrome from the Middle East. Angiology. 2010;61(8):744\u201350. https:\/\/doi.org\/10.1177\/0003319710369794.","journal-title":"Angiology."},{"issue":"6","key":"7034_CR21","doi-asserted-by":"publisher","first-page":"602","DOI":"10.7861\/clinmedicine.13-6-602","volume":"13","author":"RA Henderson","year":"2013","unstructured":"Henderson RA. Acute coronary syndrome: optimising management through risk assessment. Clin Med. 2013;13(6):602\u20136. https:\/\/doi.org\/10.7861\/clinmedicine.13-6-602.","journal-title":"Clin Med"},{"key":"7034_CR22","doi-asserted-by":"crossref","unstructured":"Dakhil Z, Alsuz I. How can an ideal healthcare system enhance the decision making of heart team in critical situations? J Am Coll Cardiol. 2020;75(11 Supplement 1):3546.","DOI":"10.1016\/S0735-1097(20)34173-5"},{"key":"7034_CR23","unstructured":"France24.com [Internet]. Iraq doctors say vendettas threaten their lives as they save others. Accessed at April 2019. Available at: https:\/\/www.france24.com\/en\/20190228-iraq-doctors-say-vendettas-threaten-lives-they-save-others."},{"issue":"22","key":"7034_CR24","doi-asserted-by":"publisher","first-page":"2435","DOI":"10.1016\/j.jacc.2010.03.007","volume":"55","author":"KA Fox","year":"2010","unstructured":"Fox KA, Clayton TC, Damman P, Pocock SJ, de Winter RJ, Tijssen JG, et al. FIR collaboration. Long-term outcome of a routine versus selective invasive strategy in patients with non\u2013ST-segment elevation acute coronary syndrome: a meta-analysis of individual patient data. J Am Coll Cardiol. 2010;55(22):2435\u201345. https:\/\/doi.org\/10.1016\/j.jacc.2010.03.007.","journal-title":"J Am Coll Cardiol"},{"issue":"2","key":"7034_CR25","doi-asserted-by":"publisher","first-page":"185","DOI":"10.1002\/ccd.28280","volume":"95","author":"M Barbarawi","year":"2019","unstructured":"Barbarawi M, Kheiri B, Zayed Y, Barbarawi O, Chahine A, Haykal T, et al. Meta-analysis of optimal timing of coronary intervention in non-ST-acute coronary syndrome. Catheter Cardiovasc Interv. 2019;95(2):185\u201393. https:\/\/doi.org\/10.1002\/ccd.28280.","journal-title":"Catheter Cardiovasc Interv"},{"issue":"24","key":"7034_CR26","doi-asserted-by":"publisher","first-page":"2741","DOI":"10.1161\/CIRCULATIONAHA.118.037152","volume":"138","author":"KF Kofoed","year":"2018","unstructured":"Kofoed KF, Kelb\u00e6k H, Hansen PR, Torp-Pedersen C, H\u00f8fsten D, Kl\u00f8vgaard L, et al. Early versus standard care invasive examination and treatment of patients with non-ST-segment elevation acute coronary syndrome VERDICT randomized controlled trial. Circulation. 2018;138(24):2741\u201350. https:\/\/doi.org\/10.1161\/CIRCULATIONAHA.118.037152.","journal-title":"Circulation."}],"container-title":["BMC Health Services Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-021-07034-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1186\/s12913-021-07034-7\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1186\/s12913-021-07034-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2021,9,26]],"date-time":"2021-09-26T20:11:12Z","timestamp":1632687072000},"score":1,"resource":{"primary":{"URL":"https:\/\/bmchealthservres.biomedcentral.com\/articles\/10.1186\/s12913-021-07034-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,9,26]]},"references-count":26,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2021,12]]}},"alternative-id":["7034"],"URL":"https:\/\/doi.org\/10.1186\/s12913-021-07034-7","relation":{},"ISSN":["1472-6963"],"issn-type":[{"value":"1472-6963","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,9,26]]},"assertion":[{"value":"4 November 2020","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"15 September 2021","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"26 September 2021","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national Iraqi guidelines and with the Helsinki Declaration of 1975, as revised in 2008, this study is part of a clinical audit on management of NSTE-ACS that has been approved by the ethical and scientific committee in Scientific Council of Cardiology\/ Iraqi Board for Medical Specializations. Written informed consent was obtained from all the participants.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethics approval and consent to participate"}},{"value":"Not applicable.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Consent for publication"}},{"value":"Not applicable.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"1015"}}