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Risk factor management after acute coronary syndromes
  1. Chiara Melloni,
  2. L Kristin Newby
  1. Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
  1. Correspondence to Dr L K Newby, Duke Clinical Research Institute, PO Box 17969, Durham, NC 27715-7969, USA; newby001{at}

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Considerable resources in most healthcare systems and hospitals are devoted to measuring, improving and ensuring quality of care. In no other disease area is this a more prominent focal point than in cardiovascular disease. Randomised clinical trials have clearly proven benefits from a number of treatments for patients presenting with acute coronary syndromes, and their results are the foundation of guideline recommendations world wide.1,2,3,4,5 These recommended treatments range from inexpensive, non-invasive and relatively low-risk interventions, such as the use of aspirin, to more invasive and/or higher-risk interventions like coronary angiography and revascularisation.

Over the past decade, recognition of the presence of a wide gap between the quality of the care delivered and the quality of the care recommended has led to the development of performance measures and the institution of quality improvement programmes that could document clinically relevant quality indicators in the treatment of patients with ST-segment elevation and non-ST-segment elevation myocardial infarction, and promote quality improvement.

Highly recognised programmes are the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) Quality Improvement initiative, now merged with NRMI (National Registry for Myocardial Infarction) to create the NCDR-ACTION (National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network) Registry (, accessed 2 June 2009), the ACC Guidelines Applied in Practice (GAP) programme6 and the American Heart Association’s Get With The Guidelines-Coronary Artery Disease (GWTG-CAD)7 programme. These have provided approaches to data collection and feedback to hospitals on their performance relative to class I guideline recommendations for acute treatment (aspirin, β blocker, heparin and glycoprotein IIb/IIIa inhibitors within 24 h, early angiography in high-risk patients), discharge treatment (aspirin, β blocker, statin, angiotensin converting …

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