Management of Patients with NSTE ACS Latest Insights from CRUSADE A National Quality Improvement Initiative

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Management of Patients with NSTE ACSLatest
Insights from CRUSADE A National Quality
Improvement Initiative
Eric D. Peterson, MD, MPHDuke Clinical Research
InstituteDuke University Medical CenterDurham,
North Carolina
Author Disclosures Research and speaker support
from Millennium, Schering Plough, BMS, Sanofi.
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Goals for CRUSADE Improve Adherence to ACC/AHA
Guidelines Improve Patient Outcomes
Acute Therapy
Discharge Therapy

• Aspirin
• Clopidogrel
• Beta Blocker
• Heparin (UFH or LMWH)
• GP IIb-IIIa Inhibitor
• Cath/PCI

• Aspirin
• Clopidogrel
• Beta Blocker
• ACE Inhibitor
• Statin/Lipid Lowering
• Smoking Cessation
• Cardiac Rehabilitation

2002 ACC/AHA Guidelines Update
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CRUSADE Site Distribution
Sites Who Have Submitted 486
WA (8)
ME (1)
VT (1)
ND (1)
MT (0)
MI
NH (2)
MN (4)
NY (36)
OR (5)
MA (11)
WI (5)
SD (2)
ID (0)
MI (24)
RI (1)
WY (0)
CT (8)
PA (39)
IA (4)
NJ (10)
NE (4)
OH (30)
DE (3)
NV (3)
IL (15)
IN (9)
WV (3)
MD (13)
VA (16)
UT (1)
CO (8)
KY (8)
KS (3)
MO (12)
DC (1)
CA (36)
NC (13)
TN (15)
SC (6)
OK (8)
AR (4)
AZ (9)
NM (2)
AL (11)
GA (15)
MS (7)
LA (8)
TX (17)
FL (33)
AK (0)
HI (1)
Last updated 1/28/05
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CRUSADE DATA SUBMISSIONFrom 486 Sites
130,735!
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Representation of ElderlyCommunity vs. RCT
Population
Age gt75
Decade
Lee, JAMA, 2001
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Gender and Age NSTE ACS
of population
Patient Age
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Age and Comorbid Illness
of population
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Creatinine Clearance and AgeVIGOUR Trials and
CRUSADE
Median Creatinine Clearance
Patient Age (Yrs)
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Acute Medication Use Q3 2004(Within 1st 24
hours in patients without contraindications)
96
100
91
88
80
55
60
46
40
20
0
Beta Blockers
Heparin (LMW UFH)
GP IIb-IIIa Inhibitors
Clopidogrel
ASA
Q4 2004 CRUSADE data
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Trends in Acute Therapy Adherence (Among
Patients Without Contraindications)
Quarter 1, 2002 through Quarter 4, 2004
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Invasive Cardiac Procedures Q4 2004(Among
Patients Without Contraindications to Cath)
90
82
75
75
61
60
60
52
45
45
40
55
30
30
12
15
15
0
0
Cath
Cath
Cath lt 48 hr
PCI
CABG
PCI lt 48 hr
Cath lt 48 hr
PCI
CABG
PCI lt 48 hr
Q4 2004 CRUSADE Data
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Trends in Invasive Procedure Use (Among Patients
Without Contraindications to Cath)
Quarter 1, 2002 through Quarter 4, 2004
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The Train Speeds Up.Faster Cardiac
Catheterization
Among those receiving cath
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The Train Speeds Up.Shrinking In-hospital ACS
Care
lt3 Days 35 vs 47
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Discharge Medication Use Q4 2004 (In patients
without contraindications)
100
94
91
88
80
72
69
60
40
20
0
ASA
Beta Blockers
ACE- or ARB
Any Lipid- Lowering Agent
Clopidogrel
LVEF lt 40, CHF, DM, HTN Known hyperlipidemia,
? TC, ? LDL
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Trends in Discharge Therapy(Among Patients
Without Contraindications)
Quarter 1, 2002 through Quarter 4, 2004
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Overall Adherence Trends Over Time Quarter 1,
2002 Quarter 3, 2004
Quarter 1, 2002 through Quarter 4, 2004
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Need Right Drug but Also Right DoseExcessive
Antithrombotic Dosing by Age
Q1-Q2 2004 CRUSADE data
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Consequences of Excessive DosingRBC
Transfusions by Dose Excess
RBC Transfusion ()
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Does it Matter? Mortality Rates by of Acute
Guideline Recommended Therapies Received
Adjusted OR 0.72 (0.68,0.76)
In-hospital Mortality
Number of Recommended Therapies
Therapies Acute Aspirin, Acute Beta-blockers,
Acute Heparin, GP IIb/IIIa inhibitors, Cardiac
Catheterization lt48 hours
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Mortality Rates by of Acute Guideline
Recommended Therapies Received by Age Group
Age Group
Adj. OR
0.71 (0.67,0.75) 0.79 (0.75,0.83)
In-hospital Mortality
Number of Recommended Therapies
Therapies Acute Aspirin, Acute Beta-blockers,
Acute Heparin, GP IIb/IIIa inhibitors, Cardiac
Catheterization lt48 hours
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Mortality Rates by of Acute Guideline
Recommended Therapies Received by Risk Group
Risk Group
In-hospital Mortality
Number of Recommended Therapies
Therapies Acute Aspirin, Acute Beta-blockers,
Acute Heparin, GP IIb/IIIa inhibitors, Cardiac
Catheterization lt48 hours Based on CRUSADE Risk
Score
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Latest Results in NSTE ACS in US Conclusions

• Crusade continues to represent real world NST
  ACS
• Older patients
• More comorbidity
• Care for NSTE ACS is improving
• Continued progress in adherence to ACC/AHA
  Guidelines for both acute and discharge
  treatments
• More early cath, leading to earlier discharge
• Yet opportunities for improvement persist
• Largest gaps acute GP IIb/IIIa, D/C ACE,
  clopidogrel
• Right dosing to reduce adverse events
• And can lead to even better patient outcomes!