Utilization of early invasive management strategies for high-risk patients with non-ST-segment elevation acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative.
BACKGROUND
The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials.


OBJECTIVE
To determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality.


METHODS
The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative evaluated care patterns and outcomes for 17,926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002.


METHODS
Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality. Results Of the 17,926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001). Conclusions An early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy appears to be reserved for patients without significant comorbidities and those cared for by cardiologists and is associated with a lower risk of in-hospital mortality.
Bhatt
Deepak L
DL
Cleveland Clinic Foundation, Department of Cardiovascular Medicine/Desk F25, Cleveland, Ohio 44195, USA. bhattd@ccf.org
Roe
Matthew T
MT
Peterson
Eric D
ED
Li
Yun
Y
Chen
Anita Y
AY
Harrington
Robert A
RA
Greenbaum
Adam B
AB
Berger
Peter B
PB
Cannon
Christopher P
CP
Cohen
David J
DJ
Gibson
C Michael
CM
Saucedo
Jorge F
JF
Kleiman
Neal S
NS
Hochman
Judith S
JS
Boden
William E
WE
Brindis
Ralph G
RG
Peacock
W Frank
WF
Smith
Sidney C
SC
Pollack
Charles V
CV
Gibler
W Brian
WB
Ohman
E Magnus
EM
D000368:Aged; D000369:Aged, 80 and over; D000789:Angina, Unstable / Q000401:mortality / Q000628:therapy*; D015906:Angioplasty, Balloon, Coronary / Q000706:statistics & numerical data; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000401:mortality / Q000628:therapy*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D017063:Outcome Assessment, Health Care; D012307:Risk Factors; D013997:Time Factors