Care of non-ST-segment elevation patients: Insights from the crusade national quality improvement initiative

doi:10.1016/j.ahj.2004.09.013

American Heart Journal

Volume 148, Issue 5, Supplement, November 2004, Pages S34-S39

https://doi.org/10.1016/j.ahj.2004.09.013 Get rights and content

Abstract

Acute coronary syndromes (ACS), including non-ST-segment elevation (NSTE) ACS, represent a significant source of morbidity and mortality in the United States. To address this widespread, serious health problem, the American College of Cardiology and the American Heart Association (ACC/AHA) published guidelines for the treatment of NSTE ACS, which include unstable angina (UA) and NSTE myocardial infarction (NSTEMI). These ACC/AHA guidelines are intended to help physicians make appropriate decisions when diagnosing and treating patients with NSTE ACS.

Section snippets

CRUSADE background

As of 2003, some 77,000 patients in 47 states across the United States have been analyzed in the CRUSADE project. In addition to revealing the degree of guideline adherence, the CRUSADE data allow us to

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Ascertain the value of the guidelines
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Identify undertreated patient populations
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Evaluate the quality of patient care plus the relationship between quality of care and patient outcome
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Apply knowledge gained from clinical trials to the most seriously ill patients at CRUSADE hospitals.

We are

Does quality of care matter?

Peterson et al have reported an association between the degree of adherence to ACC/AHA guidelines and better patient outcomes.¹ Using CRUSADE data, the authors evaluated patient outcome for 65,426 patients with ischemic ST-segment electrocardiogram (ECG) changes and/or positive cardiac markers. Hospitals were grouped into quartiles, based on their reported overall adherence to ACC/AHA guidelines. Hospitals with >80% adherence to these guidelines (leading quartile) were compared with hospitals

Care by primary treating physician

In 2003, Peterson et al examined CRUSADE data for approximately 19,000 high-risk ACS patients with positive cardiac markers and/or ST depression and found that patient outcome is influenced by the primary treating physician's area of medicine.² The authors reported that 43% of patients were cared for by noncardiologists and that NSTE ACS patients treated by noncardiologists are significantly less likely to receive guideline-adherent treatment than are patients treated by cardiologists. This is

Who are the undertreated?

Because ACC/AHA guideline adherence is associated with better patient outcome, high-risk patients with NSTE ACS should receive treatment that most closely adheres to the guidelines. High-risk groups identified in CRUSADE include the elderly, women, patients with diabetes, patients with congestive heart failure (CHF), and patients with elevated serum troponin levels. Guideline adherence was assessed for each of these high-risk groups.

Elderly patients

Alexander and colleagues analyzed CRUSADE data concerning acute and discharge treatment of the elderly with NSTE ACS.³ Therapies of patients ≥75 years old were compared with those of patients <75 years old. Medications delivered within the first 24 hours and at discharge were evaluated. In the first 24 hours, aspirin and β-blockers were delivered with similar frequency in both age groups. However, clopidogrel and GP IIb/IIIa inhibitors were dispensed to the elderly at notably lower rates than

Female patients

An evaluation of CRUSADE data from Q4 2003 that compared acute risks and treatments among men and women with NSTE ACS revealed a higher risk of adverse outcomes in women. The women presenting with NSTE ACS demonstrated a higher percentage of death overall than did the men (5.6% vs 4.3%), a greater incidence of cardiac death and MI (8.6% vs 7.1%), and a greater incidence of CHF (12.1% vs 8.8%).¹

In this same population of NSTE ACS patients, women were treated in accordance with ACC/AHA guidelines

Patients with diabetes

A similar investigation of acute risks and treatments of NSTE ACS in patients with diabetes revealed a higher risk of adverse outcomes for the patients with diabetes. Among NSTE ACS patients, those with diabetes demonstrated a higher percentage of death overall compared to patients without diabetes (5.7% vs 4.3%). Those with diabetes also exhibited a higher rate of cardiac death and recurrent MI than those without diabetes (8.6% vs 7.2%), and a greater incidence of heart failure (13.8% vs 8.5%).

Patients with CHF

Another analysis of CRUSADE data from Q4 2003 revealed a higher risk of adverse outcomes in patients with CHF. In this population, patients with CHF demonstrated a much higher percentage of death overall as compared to non-CHF patients (10.6% vs 3.1%) and a higher percentage of cardiac death and recurrent MI (14.7% vs 5.7%).¹

NSTE ACS patients with CHF received recommended treatments at a far lower rate than did those without CHF. Cardiac catheterization within the first 48 hours was performed

Patients with elevated serum troponin levels

The ACC/AHA guidelines as revised in 2002 recommend an early invasive strategy for patients with NSTE ACS without serious comorbidity and who have any high-risk indicators including elevated troponin T (TnT) or troponin I (TnI).⁴ Approximately 97% of patients in CRUSADE underwent baseline serum troponin screening. Examination of CRUSADE data confirmed the observations of others that, as serum troponin levels rise from normal to 5 times the upper limit of normal (ULN), the mortality rate

CRUSADE outcomes observations

As of 2003, CRUSADE included >77,000 patients from 430 participating sites, a much larger population than is seen in even the largest controlled clinical trials. We have examined the CRUSADE patient population to see if it matches and supports the findings from controlled clinical trials and perhaps extends these findings to a much wider population not studied in clinical trials. We have also correlated mortality and peak troponin levels, the early use of GP IIb/IIIa inhibitors, and the use of

Comparison to clinical trials data

CRUSADE data demonstrate that, as the peak serum troponin ratio rises from 1 to 10, the risk of mortality rises almost linearly, from about 2% to almost 6%. These findings are in support of previously published clinical trials data.⁸

Early use of GP IIb/IIIa inhibitors has been shown to be beneficial in controlled clinical trials and is recommended by the ACC/AHA guidelines for treatment of NSTE ACS.⁹ While CRUSADE reflects observational data rather than prospective controlled clinical trial

CRUSADE trend data

A major objective of CRUSADE is to improve the care of high-risk patients with NSTE ACS. To that end, CRUSADE data are reported back to each participating institution in order to highlight both individual hospital adherence and national adherence to the ACC/AHA guidelines for the management of patients with NSTE ACS, and, over time, to encourage better adherence to those guidelines. The 4 quarters of calendar year 2003 have been analyzed and compared to ascertain trends in adherence to the

Conclusion

The goal of CRUSADE is to improve adherence to the ACC/AHA guidelines for the management of NSTE ACS. Whereas the value of guideline adherence has been demonstrated, the undertreatment of high-risk patients is cause for concern. Data that compare CRUSADE results with that of clinical trials support many findings of controlled clinical trials. Furthermore, the benefits of guideline adherence—and the resulting improved patient outcomes—have been shown to be extended to our most seriously ill

Summary of points learned from crusade

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Adherence to guidelines is associated with lower in-hospital mortality among patients with high-risk NSTE ACS, suggesting that quality care does matter.
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Patients with even modest elevations of serum troponin levels have increased mortality but are undertreated.
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Elderly patients and other high-risk NSTE ACS patients are less likely to receive ACC/AHA-guideline-compliant therapies.
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CRUSADE has shown modest gains in achieving better ACC/AHA guideline adherence to date.

References (11)

E.D. Peterson et al.
Early use of glycoprotein IIb/IIIa inhibitors in non-ST-elevation acute myocardial infarction: observations from the National Registry of Myocardial Infarction 4
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E. Boersma et al.
Platelet glycoprotein IIb/IIIa inhibitors in acute coronary syndromes; a meta-analysis of all major randomised clinical trials
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Peterson ED, Roe MT, Li Y, Influence of physician specialty on care and outcomes of acute coronary care patients:...
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Elderly not receiving recommended early interventions for acute coronary syndromes: Update from CRUSADE
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