ISCHAEMIC HEART DISEASE

More proof that use of the correct medication saves lives in ACS▸

Data from the > 20 000 patients in the GRACE registry of acute coronary syndromes (ACS) suggests several important take-home messages. This study focused on quality of care. Use of medications in eligible patients at discharge ranged from 73% for angiotensin converting enzyme (ACE) inhibitors to 93% for aspirin. High risk features (for example, heart failure, older age) were related to failure to use aspirin and β blockers. Being treated at a teaching hospital and care by a cardiologist were associated with greater use of aspirin and β blockers. Coronary artery bypass surgery (CABG) was associated with failure to use ACE inhibitors and aspirin. When hospitals were divided into quartiles of quality performance, adjusted in-hospital mortality was 4.1% in the top versus 5.6% in the bottom quartile, representing a 27% (95% confidence interval (CI) 11% to 42%) lower relative mortality. So, special care to ensure appropriate use of medical treatments seems warranted, especially for patients looked after in smaller hospitals, cared for by non-cardiologists, or having CABG.

Pre-treatment with clopidogrel after thrombolysis reduces risk from PCI▸

In PCI-CLARITY, > 1800 patients received aspirin and were randomised to receive either clopidogrel (300 mg loading dose, then 75 mg once daily) or placebo initiated with fibrinolysis and given until coronary angiography, which was performed 2–8 days after initiation of the study drug. For patients undergoing coronary artery stenting, it was recommended that open label clopidogrel (including a loading dose) be administered after the diagnostic angiogram. The primary outcome was the incidence of the composite of cardiovascular death, recurrent myocardial infarction (MI), or stroke from percutaneous coronary intervention (PCI) to 30 days after randomisation. Secondary outcomes included MI or stroke before PCI and the aforementioned composite from randomisation to 30 days. Pretreatment with clopidogrel reduced the incidence of MI or stroke before PCI (37 (4.0%) v 58 (6.2%); odds ratio (OR) 0.62, …