The treatment-risk paradox: Do high-risk patients get the treatment they deserve?

Current guidelines for the treatment of ACS call for early risk stratification followed by an aggressive diagnostic and therapeutic approach for patients at high risk of adverse events. These guidelines are based on randomized clinical trials demonstrating that therapies such as low-molecular-weight heparins, glycoprotein IIb/IIIa inhibitors, and an early invasive reperfusion strategy are of particular benefit to high-risk patients. Among lower-risk patients, the risks associated with these therapies may outweigh the potential benefits. Recently, analyses from large ACS registries have suggested that clinicians are more likely to offer these therapies to low-risk patients than to those at high risk. This observation has been termed the "treatment-risk paradox". In this review, data in support of this finding are discussed, as are the potential etiologies.