Invasive management of acute coronary syndrome: Interaction with competing risks: Interaction with competing risks

Anthony (Ming yu) Chuang, David G. Hancock, Amera Halabi, Matthew Horsfall, Julian Vaile, Carmine De Pasquale, Ajay Sinhal, Dylan Jones, Richard Brogan, Derek P. Chew

Research output: Contribution to journalArticlepeer-review

8 Citations (Scopus)


Background: The aim of this study was to characterise the interaction between ACS- and non-ACS-risk on the benefits of invasive management in patients presenting with acute coronary syndrome (ACS). Methods: Consecutive patients admitted to a tertiary hospital's Cardiac Care Unit in the months of July–December, 2003–2011 with troponin elevation (>30 ng/L) were included. “ACS-specific-risk” was estimated using the GRACE score and “non-ACS-risk” was estimated using the Charlson-Comorbidity-Index (CCI). Inverse-probability-of-treatment weighting was used to adjust for baseline differences between patients who did or did not receive invasive management. A multivariable flexible parametric model was used to characterise the time-varying hazard. Results: In total, 3057 patients were included with a median follow-up of 9.0 years. Based on CCI, 1783 patients were classified as ‘low-non-ACS risk’ (CCI ≤ 1; invasive management 81%; 12-month mortality 5%), 820 as ‘medium-non-ACS risk’ (CCI 2–3; invasive management 68%; 12-month mortality 13%), and 468 as ‘high-non-ACS risk’ (CCI ≥ 4; invasive management 47%; 12-month mortality 29%). After adjustment, invasive management was associated with a significant reduction in one-year overall-mortality in the ‘low-risk’ and ‘medium-risk’ groups (HR = 0.38, 95%CI:0.26–0.56; HR = 0.46, 95%CI:0.32–0.67); but not in the ‘high-risk’ group (HR = 1.02, 95%CI:0.67–1.56). The absolute benefit of invasive management was greatest with higher baseline ACS-risk, with a non-linear interaction between ACS- and non-ACS-risk. Conclusions: There is a complex interaction between ACS- and non-ACS-risk on the benefit of invasive management. These results highlight the need to develop robust methods to objectively quantify risk attributable to non-ACS comorbidities in order to make informed decisions regarding the use of invasive management in individuals with numerous comorbidities.

Original languageEnglish
Pages (from-to)13-18
Number of pages6
JournalInternational Journal of Cardiology
Publication statusPublished or Issued - 15 Oct 2018
Externally publishedYes


  • Acute coronary syndromes
  • Flexible parametric
  • Percutaneous coronary intervention
  • Propensity score

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine

Cite this