title: The implementation of guidelines and prognosis among patients with acute coronary syndromes is influenced by physicians' perception of antecedent physical and cognitive status.
abstract: OBJECTIVE
  Physicians' perception of antecedent physical/cognitive status may account for the suboptimal implementation of acute coronary syndrome (ACS) guidelines.
  
  
  METHODS
  In an ACS survey of all cardiac wards, physicians' perception of antecedent physical/cognitive status was prospectively recorded and categorized as either normal, mildly impaired or significantly impaired. We examined the impact of antecedent status on the use of evidence-based medications and procedures and on mortality.
  
  
  RESULTS
  Of the 2,021 patients, 1,025 (51%) had ST elevation. Impaired antecedent physical/cognitive status was diagnosed in 417 patients (20.6%), more commonly among non-ST-elevation patients (26.2 vs. 15.2%). Patients with impaired physical/cognitive status, with or without ST elevation, had significantly worse baseline demographic and clinical characteristics. They less often received aspirin, clopidogrel, platelet glycoprotein IIb/IIIa receptor antagonists, statins and beta-adrenergic blockers, and significantly less often underwent in-hospital catheterization and revascularization. Reperfusion treatment was given significantly less frequently to ST elevation patients with impaired status (63.0% for normal vs. 50.8% and 33.3% for mildly and significantly impaired status, respectively; p = 0.001). After adjustment for differences in baseline characteristics, impaired antecedent status remained independently associated with lower use of these therapies and higher mortality rates.
  
  
  CONCLUSIONS
  ACS guideline implementation is significantly influenced by physicians' perception of antecedent physical/cognitive status, and thus is a crucial parameter for understanding ACS management and outcomes.
authors.affiliation: Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel.
authors.forename: Avital
authors.initials: A
authors.lastname: Porter
authors.forename: Zaza
authors.initials: Z
authors.lastname: Iakobishvili
authors.forename: Rita
authors.initials: R
authors.lastname: Dictiar
authors.forename: Solomon
authors.initials: S
authors.lastname: Behar
authors.forename: Hanoch
authors.initials: H
authors.lastname: Hod
authors.forename: Shmuel
authors.initials: S
authors.lastname: Gottlieb
authors.forename: Haim
authors.initials: H
authors.lastname: Hammerman
authors.forename: Doron
authors.initials: D
authors.lastname: Zahger
authors.forename: David
authors.initials: D
authors.lastname: Hasdai
mesh_terms: D000368:Aged; D000789:Angina, Unstable / Q000150:complications / Q000628:therapy*; D001291:Attitude of Health Personnel; D002908:Chronic Disease; D003072:Cognition Disorders / Q000150:complications; D005260:Female; D019983:Guideline Adherence; D006304:Health Status; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000150:complications / Q000628:therapy*; D010465:Perception; D017410:Practice Guidelines as Topic; D011379:Prognosis; D011446:Prospective Studies