scholarly journals Dropping risk stratification with subsequent treatment-risk paradox in non ST elevation acute coronary syndromes: a clinical audit in Iraq

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Zainab Atiyah Dakhil ◽  
Hasan Ali Farhan
Keyword(s):  
Chest Pain ◽  
High Risk ◽  
Risk Stratification ◽  
Cardiogenic Shock ◽  
Risk Scores ◽  
Treatment Risk ◽  
Risk Patients ◽  
Coronary Syndromes ◽  
Very High ◽  
Risk Categories

Abstract Background 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. Methods 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. Results n. = 150, 72% of them were males, mean age was (59 ± 12.32) 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 >72 h; 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. Conclusions 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.

Abstract 5585: Understanding Physicians’ Risk Stratification of Acute Coronary Syndromes: Insights from the Canadian ACS II Registry

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Andrew T Yan ◽  
Raymond T Yan ◽  
Thao Huynh ◽  
Amparo Casanova ◽  
F. E Raimondo ◽  
...  
Keyword(s):  
Risk Assessment ◽  
High Risk ◽  
Risk Stratification ◽  
Risk Score ◽  
Acute Coronary Syndromes ◽  
Risk Scores ◽  
Risk Category ◽  
Patient Risk ◽  
Treatment Risk ◽  
Coronary Syndromes

An important treatment-risk paradox exists in the management of acute coronary syndromes (ACS). However, the process of risk stratification by physicians and its relationship to patient management have not been well studied. Our objective was to examine patient risk assessment by physician in relation to treatment and objective risk score evaluation, and the underlying patient characteristics that physicians consider to indicate high risk. The prospective Canadian ACS II Registry recruited 1956 patients admitted for non-ST elevation ACS in 36 hospitals in Oct 2002-Dec 2003. Patient risk assessment by the treating physician and management were recorded on standardized case report forms. We calculated the TIMI, PURSUIT and GRACE risk scores for each patient. Of the 1956 ACS patients, 347 (17.8%) patients were classified as low risk, 822 (42%) as intermediate risk, and 787 (40.2%) as high risk by their treating physicians. Patients considered as high risk were more likely to receive aggressive medical therapies and to undergo coronary angiography and revascularization. However, there were only weak correlations (Kendall’s tau-b correlation coefficients ranging from 0.08 to 0.14) between risk assessment by physicians and all 3 validated risk scores. Advanced age was an independent negative predictor. Furthermore, there was no significant association between the high risk category and several established prognosticators, such as history of heart failure, hemodynamic variables, and creatinine. Contemporary risk stratification of ACS appears suboptimal and may perpetuate the treatment-risk paradox. Physicians may not recognize and incorporate the most powerful adverse prognosticators into overall patient risk assessment. Routine use of validated risk score may enhance risk stratification and facilitate more appropriate tailoring of intensive therapies towards high-risk patients.

Investigation of a 22-gene genomic classifier (GC) for risk stratification and molecular subtyping in an Asian prostate cancer (PCa) cohort.

2021 ◽  
Vol 39 (6_suppl) ◽  
pp. 249-249
Author(s):  
Wei Loong Sherman Yee ◽  
Wai Yee Woo ◽  
Adelene Sim ◽  
Kar Perng Low ◽  
Alice Meng ◽  
...  
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
Racial Differences ◽  
White Men ◽  
Risk Groups ◽  
Molecular Subtyping ◽  
Basal Subtype ◽  
Grid Database ◽  
Risk Patients ◽  
Very High

249 Background: A 22-gene GC has been proposed to refine risk stratification of localized PCa by conventional NCCN criteria, and this may potentially influence treatment recommendations. Nonetheless, majority of studies looking at the utility of GC were conducted in White and non-White men from Western cohorts. We therefore investigated the association of GC with NCCN risk groups (RG) in an Asian PCa cohort. Additionally, we examined for inter-racial differences in molecular subtyping between Asian and White/non-White PCa. Methods: GC (Decipher Biosciences Inc., CA) was performed on diagnostic biopsies of men who were treated with radiotherapy +/- hormonal therapy at a single institution (N = 75). ISUP Gleason’s grade (GG) and tumor cellularity were reviewed by an expert GU pathologist. RNA was extracted from 2 x 2.0-mm tumor cores using Qiagen AllPrep DNA/RNA FFPE Kit (Qiagen, Germany) and gene expression was performed on Affymetrix Human Exon 1.0 ST Array (ThermoFischer, CA). PAM50 molecular subtyping was derived using the DecipherGRID database. Results: We profiled 80 tumors from 75 patients, comprising of 18 (24.0%), 9 (12.0%), 21 (28.0%), and 19 (25.3%) NCCN low-/favorable intermediate-, unfavorable intermediate-, high- and very high-RG, respectively; of note, 8 (10.7%) patients had regional/metastatic disease at diagnosis. Using the GC, 27 (33.8%), 14 (17.5%) and 39 (48.8%) were classified as low- (<0.45), intermediate- (0.45-0.6) and high-RG, respectively (>0.6). When stratified using a three-tier clinico-genomic (CG) classification system (Spratt et al. 2017), 6 of 21 (28.6%) NCCN-defined high-risk and 4 of 19 (21.1%) very high-risk patients were downgraded to CG-defined intermediate-/low-risk, while 2 of 27 (7.4%) NCCN low-/intermediate-risk patients were in fact upgraded to CG high-risk. Next, we interrogated the PAM50 basal-luminal signature in our cohort. Interestingly, when matched to White (N = 5762) and non-White (N = 155) for NCCN RG, ISUP GG and age, we observed a high proportion of basal subtype (62.7%) in Asians, which contrasted the prevalence observed in White (16.7%) and non-White (15.9%) North American patients (Chi-sq P <0.001). Conclusions: Here, we demonstrated the utility of the 22-gene GC for refining the NCCN risk stratification in a largest Asian PCa dataset to-date. An unexpectedly high proportion of PAM50 basal-subtype was observed, suggesting race-specific differences of the tumor transcriptome.

Prognostic implications of pre-ablation stimulated Tg: a retrospective analysis of 2500 thyroid cancer patients

2021 ◽  
Author(s):  
Tian Tian ◽  
Yangmengyuan Xu ◽  
Xinyue Zhang ◽  
Bin Liu
Keyword(s):  
Thyroid Cancer ◽  
High Risk ◽  
Risk Stratification ◽  
Clinical Outcomes ◽  
Recurrent Disease ◽  
Clinicopathological Parameters ◽  
Characteristic Analysis ◽  
High Risk Patients ◽  
Risk Patients ◽  
Risk Categories

Abstract Context The risk of persistent and recurrent disease in patients with differentiated thyroid cancer (DTC) is a continuum that ranges from very low to very high, even within the three primary risk categories. It is important to identify independent clinicopathological parameters to accurately predict clinical outcomes. Objective To examine the association between pre-ablation stimulated thyroglobulin (ps-Tg) and persistent and recurrent disease in DTC patients and investigate whether incorporation of ps-Tg could provide a more individualized estimate of clinical outcomes. Design, Setting, and Participants Medical records of 2524 DTC patients who underwent total thyroidectomy and radioiodine ablation between 2006 and 2018 were retrospectively reviewed. Main Outcome Measure Ps-Tg was measured under thyroid hormone withdrawal before remnant ablation. Association of ps-Tg and clinical outcomes. Results In multivariate analysis, age, ATA risk stratification, M1, ps-Tg and cumulative administered activities were the independent predictive factors for persistent/ recurrent disease. Receiver operating characteristic analysis identified ps-Tg cutoff (≤ 10.1 ng/mL) to predict disease free status with a negative predictive value of 95%, and validated for all ATA categories. Integration of ps-Tg into ATA risk categories indicated that the presence of ps-Tg ≤ 10.1 ng/mL was associated with a significantly decreased chance of having persistent/recurrent disease in intermediate- and high-risk patients (9.9 to 4.1% in intermediate-risk patients, and 33.1 to 8.5% in high-risk patients). Conclusion Ps-Tg (≤ 10.1 ng/mL) was a key predictor of clinical outcomes in DTC patients. Its incorporation as a variable in the ATA risk stratification system could more accurately predict clinical outcomes.

Cardiovascular risk assessment in diabetes and pre-diabetes

ESC CardioMed ◽  
2018 ◽  
pp. 923-924
Author(s):  
Nikolaus Marx
Keyword(s):  
Risk Assessment ◽  
Cardiovascular Risk ◽  
High Risk ◽  
Target Organ Damage ◽  
Risk Scores ◽  
High Risk Patients ◽  
Patients With Diabetes ◽  
Risk Patients ◽  
Artery Disease ◽  
Very High

Patients with diabetes exhibit an increased propensity to develop cardiovascular disease with an increased mortality. Early risk assessment, especially for coronary artery disease, is important to initiate therapeutic strategies to reduce cardiovascular risk. This chapter reviews the current literature on risk scores in patients with type 1 and type 2 diabetes and summarizes the role of risk assessment based on biomarkers and different imaging strategies. Current guidelines recommend that patients with diabetes are characterized as high-risk or very high-risk patients. In the presence of target organ damage or other risk factors such as smoking, marked hypercholesterolaemia, or hypertension, patients with diabetes are classified as very high-risk patients while most other people with diabetes are categorized as high-risk patients.

Clinical-genomic sub-classification of high-risk prostate cancer: Implications for tailoring therapy and clinical trial design.

2020 ◽  
Vol 38 (6_suppl) ◽  
pp. 337-337
Author(s):  
Vinayak Muralidhar ◽  
Mohammed Alshalalfa ◽  
Daniel Eidelberg Spratt ◽  
Yang Liu ◽  
R. Jeffrey Karnes ◽  
...  
Keyword(s):  
Prostate Cancer ◽  
High Risk ◽  
Risk Stratification ◽  
High Risk Prostate Cancer ◽  
High Risk Disease ◽  
Risk Prostate Cancer ◽  
Risk Patients ◽  
Genomic Risk ◽  
Clinical Genomic ◽  
Very High

337 Background: Current risk stratification schema have limited prognostic performance in predicting outcome within National Comprehensive Cancer Network (NCCN) high-risk to very high-risk prostate cancer. Methods: Two multicenter high-risk cohorts were used for training (n = 214) and validation (n = 151) of a novel RNA microarray-based integrated clinical-genomic Classifier Optimized for Outcome in High-risk Prostate cancer (COOHP) to classify patients as COOHP favorable high-risk, standard high-risk, or very high-risk. Cox analysis was used to model metastasis-free survival (MFS), prostate cancer-specific survival (PCSS), and overall survival (OS). Model performance was compared to prior sub-classification systems using time-dependent c-indices. Results: Among NCCN high/very high-risk patients in the training cohort, 11% were classified as COOHP favorable high-risk, 70% as COOHP standard high-risk, and 18% as COOHP very high-risk. Patients with COOHP favorable high-risk disease had better rates of 5-year MFS compared to those with COOHP standard high-risk disease (94% vs 76%, hazard ratio [HR] 0.10, p = 0.02), and patients with COOHP very high-risk disease had worse 5-year MFS compared to those with COOHP standard high-risk disease (34% vs 76%, HR 3.5, p < 0.0001). Similarly, patients with COOHP very high-risk disease had worse 10-year PCSS compared to those with COOHP standard high-risk disease (36% vs 82%, HR 4.4, p < 0.0001). The c-indices for 5-year MFS and 10-year PCSS in the training cohort were 0.80 and 0.74, significantly improved compared to prior clinical and clinical-genomic risk stratification systems (0.62-0.69 for 5-year MFS and 0.56-0.63 for 10-year PCSS). These results were consistent in the validation cohort, where 5-year MFS significantly varied among the three COOHP subgroups (100% vs 89% vs 79%, p = 0.020), as did 10-year OS (100% vs 71% vs 53%, p = .040). Conclusions: A clinical-genomic risk stratification system specifically designed to discriminate prognosis in high-risk prostate cancer better identified favorable high-risk and very high-risk subsets of disease compared to prior clinical and clinical-genomic stratification systems.

Impact Of Revised-International Prognostic Scoring System (R-IPSS) Cytogenetic-Risk Stratification In Myelodysplastic Syndrome

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 5234-5234
Author(s):  
Maria Otazo ◽  
Sarvari Venkata Yellapragada ◽  
Matthew Zheng ◽  
Ang Li ◽  
Ruben Hernandez Perez ◽  
...  
Keyword(s):  
Overall Survival ◽  
High Risk ◽  
Risk Stratification ◽  
Median Survival ◽  
Predictive Power ◽  
Conflicts Of Interest ◽  
Biological Behavior ◽  
The Impact ◽  
Very High ◽  
Risk Categories

Abstract Background MDS encompasses a heterogeneous group of clonal marrow disorders resulting in various degree of ineffective hematopoiesis and risk of Acute Myelogenous (AML) transformation. Intuitively, the original IPSS (4-categories) lacked predictive power to dissect subgroups with more aggressive biological behavior suitable for MDS disease modifying strategies. The new coalesced R-IPPS discriminates biological subgroups and enhances predictive power based on redefined cytogenetic [5-categories-very good: -Y, del(11q); Good: e.g., normal karyotype, del(5q), del (20q); intermediate: e.g., +8,+19, del(7q); poor: e.g., -7 inv 3/del(3q), complex 3 abnormalities (abn); very poor: complex > 3 abn], depth of cytopenias and revised blast count subcategories at disease initiation, therefore allows more precise risk adapted intervention. Here, we aimed at validating the impact of cytogenetic subcategories on survival and initiated exploration of applicability of R-IPSS in our cohort of veterans diagnosed with MDS. This strategy allowed gaining insight into intrinsic disease characteristics and survival of our population. Methods From 2000-2012, 124 patients (pts) with confirmed diagnosis MDS were identified from the Michael E. Medical Center Cancer Registry. Long rank test was used to compare median Overall Survival (OS) in all generated cytogenetic and R-IPSS subgroups. Given the known effect of patient age on survival, all scored pts had survival age- adjusted using previously described formula (Greenberg. Blood. 2012). Results  Among pts studied, median age was 72 years (range, 53-91). With a median survival for the all cohort of MDS pts of 17.6 months (mo), the 3-years overall survival (OS) was 55%. In our cohort, cytogenetic classification revealed discriminative parameter from variables contained in R-IPSS with OS for very good of 32 mo (N= 10 [9.4%]), good of 26.2 mo (N=64 [59.8 %]), intermediate of 16.8 mo  (N=10 [12.8%]), poor of 12.1 mo (N=14 [16.7%]) and very poor of 4.2 mo (N=9 [7%])  (P=0.5; P=0.11; P= 0.13,P =0.08; P=0.02, respectively) (Fig.1). R-IPSS was calculated as reported. Median OS for patients in low, very low, intermediate, high and very high-risk categories were 34, 35.5, 14.5, 15, 7.8 mo, respectively (Fig.2). Age adjusted median survival estimation allowed more robust discrimination of survival with median survival of 35.5 months (mo) (P=0.8; HR=1), 18.2 mo (P=0.49; HR=1.9), 15 mo (P=0.008; HR=2.1) and 8.5mo (P=0.00; HR=4.1) for low, intermediate, high and very high-risk subgroups (Fig.3). No statistical significance difference in survival was observed between very low and low risk categories. Conclusions Our results validate the predictive value of the newly developed cytogenetic risk stratification groups contained in R-IPSS. For cytogenetic risks, clinical trends were observed across very low, low, intermediate and poor risk with significant different survival seen between poor and very poor cytogenetic groups. When taking in consideration all variables included in R-IPSS, a more precise discrimination of biological subgroups was observed after cohort age-adjustment. Larger pts samples are needed to refine difference in survival between very low and low categories. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Operative outcome of patients at low, intermediate, high and ‘very high’ surgical risk undergoing isolated aortic valve replacement with sutureless and rapid deployment prostheses: results of the SURD-IR registry

2019 ◽  
Vol 56 (1) ◽  
pp. 38-43 ◽  
Author(s):  
Giuseppe Santarpino ◽  
Paolo Berretta ◽  
Theodor Fischlein ◽  
Thierry P Carrel ◽  
Kevin Teoh ◽  
...  
Keyword(s):  
High Risk ◽  
Aortic Valve ◽  
Aortic Valve Replacement ◽  
Valve Replacement ◽  
Aortic Valve Stenosis ◽  
High Risk Patients ◽  
Risk Patients ◽  
Rapid Deployment ◽  
Very High ◽  
Risk Categories

Abstract OBJECTIVES The ideal strategy for the treatment of severe aortic valve stenosis in patients of varying risk categories has become a debated topic in the last years: should the transcatheter or surgical approach be adopted? The aim of this study was to evaluate the outcomes of low-, intermediate-, high- and very high-risk patients undergoing sutureless, rapid deployment aortic valve replacement. METHODS From 2007 to 2017, data on a total of 3651 patients were collected from the Sutureless and Rapid Deployment Aortic Valve Replacement International Registry (SURD-IR). Of these, 2057 patients who underwent primary isolated aortic valve replacement were considered for this analysis and classified as being at low (EuroSCORE <5; n = 500), intermediate (EuroSCORE 5–10; n = 901), high (EuroSCORE 11–20; n = 500) and very high (EuroSCORE >20; n = 156) preoperative risk. RESULTS Overall, a less invasive approach was used in 74.1% of patients and represented the most frequent (>50%) approach in all risk categories. The Perceval prosthesis was used more frequently than other devices, especially in patients at high and very high risk. Hospital mortality was 1.6%, 0.8%, 1.9% and 2.7% in low-, intermediate-, high- and very high-risk patients, respectively, with no significant differences among subgroups. Similarly, postoperative complication rates were similar across the different risk categories. CONCLUSIONS Surgical aortic valve replacement using sutureless, rapid deployment biological valve prostheses is associated with excellent results and represents a safe and effective treatment option for patients with severe aortic valve stenosis. This seems to be particularly true in patients with a higher risk profile.

C0024 Nicotinic acid/laropiprant addition to chronic lipid apheresis in very high-risk patients with acute coronary syndromes

2012 ◽  
Vol 130 ◽  
pp. S135-S136
Author(s):  
Gabriele Cioni ◽  
Rossella Marcucci ◽  
Lucia Mannini ◽  
Sandra Fedi ◽  
Stefano Bucci ◽  
...  
Keyword(s):  
High Risk ◽  
Nicotinic Acid ◽  
Acute Coronary Syndromes ◽  
Lipid Apheresis ◽  
High Risk Patients ◽  
Risk Patients ◽  
Coronary Syndromes ◽  
Very High

scholarly journals Patients Risk Stratification in the Management of Osteoporosis: the Latest International Guidelines

2021 ◽  
Vol 47 (3) ◽  
pp. 8-16
Author(s):  
Siok Bee Chionh
Keyword(s):  
High Risk ◽  
Risk Stratification ◽  
Fragility Fracture ◽  
Pharmacological Agent ◽  
Oral Bisphosphonates ◽  
Moderate Risk ◽  
International Guidelines ◽  
Anabolic Agent ◽  
Risk Patients ◽  
Very High

Assessment of risk of a fragility fracture is a vital step a physician needs to undertake in every patient suspected of osteoporosis, as this will influence the decisions on whether to treat with a pharmacological agent, with which drug, and for how long. After risk stratification, patients deemed Very High-Risk should be considered for an anabolic agent, or if this is not feasible, a parenteral anti-resorptive. High- Risk or Moderate-Risk patients may be considered for oral bisphosphonates.

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