An examination of clinical intuition in risk assessment among acute coronary syndromes patients: observations from a prospective multi-center international observational registry.

Background: As there are limited data evaluating "clinical intuition" in risk prediction among acute coronary syndromes (ACS) patients. We evaluated the relationship between perceived and "scored" risk in ACS patients, and their association with care and outcome.

Methods And Results: Within a prospective multi-center international ACS study from 58 hospitals in Australia, China, India and Russia enrolling patients between May 2009 and February 2011, at least 2 physicians involved in each patient's care estimated the patient's untreated risk, and the change in risk with invasive management. The association between clinical factors and physician perceived risk was assessed with multilevel mixed-effects regression models. Risk underestimation was defined as when physician-predicted risk was lower than GRACE score calculated risk and was used to compare clinical care and 6 month mortality. In total, 1542 patients and 4230 patient-specific physicians' estimates were obtained. By 6 months 48/1542 (3.1%) of patients had died compared with an estimated rate of 2.5% with full treatment. Advanced age, hypotension, tachycardia and ST changes on ECG were associated with increased perceived risk, while female gender was associated with lower perceived risk. Clinician risk underestimation was associated with less guideline therapy and higher 6-month mortality (not underestimated: 10/967 (1.0%) vs. one physician underestimated: 25/429 (5.8%) vs. all physician's underestimated: 13/146 (8.9%), any underestimation vs. no underestimation adjusted OR: 6.0 [95% CI: 2.3-15.5, p<0.001]).

Conclusions: Clinical risk prediction using established risk characteristics is not consistently observed in clinical practice. Studies evaluating the implementation and outcomes associated with objective risk prediction are warranted.