Recent trends in the care of patients with non-ST-segment elevation acute coronary syndromes: insights from the CRUSADE initiative.
BACKGROUND
The extent to which national health quality improvement initiatives have altered reported treatment gaps among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unknown. We sought to determine recent trends in adherence to guideline-based therapies for NSTE ACS.


METHODS
We evaluated the treatment of patients with high-risk (positive cardiac markers and/or ischemic ST-segment changes) NSTE ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA (American College of Cardiology/American Heart Association) Guidelines (CRUSADE) Quality Improvement Initiative from 2002 through 2004 (a total of 113 595 patients over 11 calendar quarters). We analyzed adherence to guideline-recommended therapies, including medications used in the acute care period (<24 hours after presentation), invasive procedures, in-hospital outcomes, and discharge therapies and interventions.


RESULTS
The use of each class I guideline recommendation, as well as overall adherence to the guidelines, improved significantly (P<.001) during the study period. In the acute care setting, the use of antiplatelet agents increased by 5% and beta-blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and beta-blockers by 8%. Heparin use in the acute care period increased by 6%, largely owing to a 9% increase in the use of low-molecular-weight heparin. Use of glycoprotein IIb/IIIa inhibitors in the acute care period also increased by more than 13%. At discharge, clopidogrel use increased by 22%, lipid-lowering agents by 11%, and angiotensin-converting enzyme inhibitors by 5%. While adherence improved, many patients still failed to receive 100% indicated treatments at the end of the study period.


CONCLUSIONS
During the 4 years since the initial release of the ACC/AHA guidelines for NSTE ACS, adherence to class I recommendations has significantly improved among hospitals participating in CRUSADE. Still, further improvements are needed for optimal implementation of the these guidelines.
Mehta
Rajendra H
RH
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA. mehta007@dcri.duke.edu
Roe
Matthew T
MT
Chen
Anita Y
AY
Lytle
Barbara L
BL
Pollack
Charles V
CV
Brindis
Ralph G
RG
Smith
Sidney C
SC
Harrington
Robert A
RA
Fintel
Dan
D
Fraulo
Elizabeth S
ES
Califf
Robert M
RM
Gibler
W Brian
WB
Ohman
E Magnus
EM
Peterson
Eric D
ED
D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D000789:Angina, Unstable / Q000453:epidemiology / Q000628:therapy*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D006328:Cardiac Catheterization / Q000706:statistics & numerical data; D000077144:Clopidogrel; D001026:Coronary Artery Bypass / Q000706:statistics & numerical data; D003376:Counseling; D004363:Drug Utilization / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data* / Q000639:trends; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008019:Life Style; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000453:epidemiology / Q000628:therapy*; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D019039:Platelet Glycoprotein GPIIb-IIIa Complex / Q000037:antagonists & inhibitors; D017410:Practice Guidelines as Topic; D011785:Quality Assurance, Health Care; D016540:Smoking Cessation; D013988:Ticlopidine / Q000031:analogs & derivatives / Q000627:therapeutic use; D014481:United States
D000319:Adrenergic beta-Antagonists; D000806:Angiotensin-Converting Enzyme Inhibitors; D000925:Anticoagulants; D000960:Hypolipidemic Agents; D010975:Platelet Aggregation Inhibitors; D019039:Platelet Glycoprotein GPIIb-IIIa Complex; D006493:Heparin; D000077144:Clopidogrel; D013988:Ticlopidine