Use of guidelines-recommended management and outcomes among women and men with low-level troponin elevation: insights from CRUSADE.

BACKGROUND: Troponin elevation above the upper limit of normal (ULN) is diagnostic of myocardial infarction, but interpretation of "gray-zone" troponin elevations (1 to 1.5x ULN) remains uncertain. Using the CRUSADE database, we explored relationships between sex and treatment and outcomes among patients with troponin 1 to 1.5x ULN. METHODS AND RESULTS: We compared treatment and outcomes among women and men using logistic generalized estimating equation method. Overall, 5049 of 85 671 (5.9%) non-ST-segment elevation acute coronary syndromes patients (2156 women, 2893 men) had troponin 1 to 1.5x ULN within 24 hours of presentation. Compared with troponin >1.5x ULN, "gray-zone" patients less often received all guidelines-indicated acute (mean composite score, 63% versus 72%) and discharge therapies (mean composite score, 73% versus 78%), but received them more frequently than patients with troponin <1x ULN (mean composite scores, 58% acute and 67% discharge). Among "gray-zone" patients, acute and discharge therapy use was similar between women and men, except acute aspirin (adjusted odds ratio, 0.80 [95% CI, 0.65 to 0.98]) and discharge angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.77 [95% CI, 0.67 to 0.88]). "Gray-zone" patients had lower mortality (2.3%) than the >1.5x ULN (4.5%) group but higher than the <1x ULN group (1.1%). Outcomes were similar among "gray-zone" women and men (adjusted odds ratios: death, 0.88 [95% CI, 0.58 to 1.35]; death/myocardial infarction, 0.77 [95% CI, 0.55 to 1.06]; transfusion, 1.04 [95% CI, 0.85 to 1.27]). CONCLUSIONS: Patients with non-ST-segment elevation acute coronary syndromes and low-level troponin elevations had lower overall risk and received less aggressive guidelines-based treatment than those with greater troponin elevations, but treatment patterns were largely similar by sex across troponin elevation groups.

Hypercholesterolemia paradox in relation to mortality in acute coronary syndrome.

BACKGROUND: Hypercholesterolemia is a risk factor for coronary artery disease, yet is associated with lower risk of adverse outcomes in patients with acute coronary syndromes (ACS). HYPOTHESIS: We explored this paradox in 84,429 patients with non-ST-segment elevation ACS in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines registry. METHODS: We examined the association between a history of hypercholesterolemia and in-hospital mortality after adjusting for clinical covariates. After excluding patients with previously diagnosed hypercholesterolemia, we repeated the analysis, examining the association between newly diagnosed hypercholesterolemia (in-hospital low-density lipoprotein cholesterol [LDL-C] > or = 100 mg/dL) and mortality. RESULTS: A history of hypercholesterolemia was associated with lower in-hospital mortality (unadjusted odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.55, 0.62). This protective association persisted after adjusting for baseline characteristics (OR: 0.71; 95% CI: 0.66, 0.76) and prior statin use (OR: 0.74; 95% CI: 0.68, 0.80). Among 22,711 patients with no history of hypercholesterolemia, 12,809 had a new in-hospital diagnosis of hypercholesterolemia. Unadjusted mortality in these patients was lower than among those with normal LDL levels (OR: 0.58; 95% CI: 0.50, 0.67); however, this difference was not significant after multivariable adjustment (OR: 0.86; 95% CI: 0.73, 1.01). CONCLUSIONS: The association of hypercholesterolemia with better outcomes highlights a major challenge in observational analyses. Our results suggest this paradox may result from confounding due to other clinical characteristics, impact of statin treatment, and perhaps most importantly, the fact that previously diagnosed hypercholesterolemia is a marker for patients with more prior medical contact.

Factors associated with discharge lipid-lowering drug prescription in patients hospitalized for coronary artery disease (from the Get With the Guidelines database).

Lipid-lowering therapy prevents morbidity and mortality in patients with coronary artery disease (CAD), but little is known regarding ordering practices in patients hospitalized with CAD events. Patients at participating hospitals of Get with The Guidelines-CAD, a hospital performance improvement program, were entered into a registry. Factors associated with discharge lipid-lowering therapy prescription were identified and the effect of in-hospital low-density lipoprotein cholesterol measurement on therapy prescription was evaluated. A total of 98,880 patients were enrolled at 405 hospitals. At discharge, lipid-lowering therapy was prescribed in 84.7% of patients and was associated with percutaneous coronary intervention and angiotensin-converting enzyme inhibitor, aspirin, and beta-blocker therapies at discharge, but not cardiac rehabilitation referral or coronary artery bypass grafting (all p<0.0001). After adjustment for patient characteristics, men were more likely (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.18 to 1.29; p<0.0001) and patients with heart failure were less likely to be prescribed lipid-lowering therapy (OR 0.64, 95% CI 0.59 to 0.69, p<0.0001). Patients who had low-density lipoprotein cholesterol measured during hospitalization were more likely to be prescribed lipid-lowering therapy (OR 1.56, 95% CI 1.48 to 1.65, p<0.0001). Lipid-lowering therapy prescription was associated positively with higher body mass index, history of dyslipidemia, and previous myocardial infarction and negatively with history of renal insufficiency, stroke, and hypertension. In conclusion, despite consistent benefits of lipid-lowering therapy in patients hospitalized for CAD events, discharge prescription varied by patient characteristics, in-hospital assessment, and treatment decisions. Additional efforts are needed to improve evidence-based lipid-lowering therapy prescription for eligible patients.

A framework for quality improvement: an analysis of factors responsible for improvement at hospitals participating in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative.

BACKGROUND: Hospitals are under increasing pressure to improve their quality of care. However, a key question remains: how can hospitals best design and implement successful quality improvement (QI) programs? Hospitals currently employ a variety of QI initiatives but have little empirical evidence on which to base their quality efforts. METHODS: We designed and applied a hospital cross-sectional survey to 212 hospitals participating in 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), a voluntary QI initiative of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). We factor analysis and an ordinary least squares regression model to determine the key hospital factors most associated with unexpected improvements in institutional QI in the treatment of NSTE ACS. RESULTS: From 2002 to 2004, the following factors had a significant association with unexpected increases in the 2004 QI in NSTE ACS treatment: the use of CRUSADE QI tools, clinical commitment to quality by a cardiology coadvocate, institutional financial commitment to quality, and barriers to QI related to resource availability and cultural resistance to change (all P < .10). Of these factors, optimal use of CRUSADE QI tools was associated with the highest absolute improvement in process adherence score relative to other factors. CONCLUSIONS: We identified several institutional factors associated with improved quality of care in the treatment of high-risk NSTE ACS. We hope that this evidence-based framework will help guide the development and implementation of future QI programs in order to improve the institutional quality of care for NSTE ACS.

Paradoxical use of invasive cardiac procedures for patients with non-ST segment elevation myocardial infarction: an international perspective from the CRUSADE Initiative and the Canadian ACS Registries I and II.

BACKGROUND: Practice guidelines support an early invasive strategy in patients with non-ST segment elevation acute coronary syndromes, particularly in those at higher risk. OBJECTIVES: To compare North American rates of invasive cardiac procedure use stratified by risk. METHODS: Use of invasive cardiac procedures and other care patterns in patients with non-ST segment elevation acute coronary syndromes from the United States (US) Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) National Quality Improvement Initiative (n=88,097; 465 hospitals) and Canadian ACS Registries I (n=1270; 51 hospitals) and II (n=1473; 36 hospitals) were compared after dividing patients into different risk categories based on predicted risk of in-hospital mortality. RESULTS: While the overall use of invasive procedures was higher in the US, high-risk patients were least likely to undergo coronary angiography (41% versus 64% in Canada [P<0.0001] and 53% versus 76% in the United States [P<0.0001]) and percutaneous coronary intervention (14% versus 32% in Canada [P<0.0001] and 28% versus 51% in the US [P<0.0001]) compared with low-risk patients in both countries, and had longer median waiting times for these procedures (120 h versus 96 h in Canada [P<0.0001] and 34 h versus 23 h in the US [P<0.0001] for coronary angiography). CONCLUSIONS: The inverse relationship between risk level and the use of invasive cardiac procedures for patients in the US and Canada suggests that a risk stratification-guided approach for triaging patients to an early invasive management strategy is paradoxically used. This incongruous relationship holds true regardless of resource availability or overall rates of cardiac catheterization.

Outpatient use of anticoagulants, rate-controlling drugs, and antiarrhythmic drugs for atrial fibrillation.

BACKGROUND: The first clinical practice guidelines for management of atrial fibrillation (AF) were published in 2001. We explored the use of anticoagulants, rate-controlling drugs, and antiarrhythmic drugs in patients with AF during the 4 years surrounding publication of these guidelines. METHODS: Mentions of warfarin, beta-blockers, digoxin, diltiazem, verapamil, and all class I and class III antiarrhythmic drugs made by US office-based physicians during patient visits for AF between October 1999 and September 2003 were evaluated using the IMS Health National Disease and Therapeutic Index (Plymouth Meeting, PA). Medication use by patient age, sex, and physician specialty was explored. Trends in use during the study period were estimated. RESULTS: Warfarin was mentioned in an average of 37% of all AF-related visits across the observation period, with no statistically significant change over time. Digoxin was the most commonly mentioned rate-controlling drug in 23% of patient visits, followed by beta-blockers in 11% and calcium-channel blockers in 8%. Over the study period, mentions of digoxin significantly decreased, and mentions of beta-blockers significantly increased. Mentions of antiarrhythmic drugs were reported in an average of 12% of patient visits, with no significant change over the study period. CONCLUSIONS: Observed trends in use of digoxin, beta-blockers, and class Ia antiarrhythmic drugs were consistent with evidence-based recommendations. However, only approximately one third of patient visits for AF included mentions of warfarin, even among patients aged > or = 60 years. These results indicate the need for continued education and interventions, especially regarding stroke prevention, in patients with AF.

Impact of acute beta-blocker therapy for patients with non-ST-segment elevation myocardial infarction.

PURPOSE: Early use of beta-blockers is a quality indicator for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI), despite limited data from randomized clinical trials in this population. We sought to determine the impact of acute beta-blocker therapy on outcomes in patients with NSTEMI. SUBJECTS AND METHODS: We examined acute (<24 hours) beta-blocker use in 72,054 patients with NSTEMI from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative at 509 US hospitals from 2001-2004. We analyzed patient and provider factors associated with beta-blocker use and the impact of beta-blocker therapy on unadjusted, risk-adjusted, and propensity matched outcomes in the overall sample and among selected high-risk subgroups. RESULTS: A total of 82.5% of patients without documented contraindications received acute beta-blocker therapy. Factors strongly associated with acute beta-blocker use included prior beta-blocker use, higher presenting systolic blood pressure, lower heart rate, lack of signs of heart failure, and cardiology care. Acute beta-blocker use was associated with lower in-hospital mortality (unadjusted 3.9% vs 6.9%, P <.001, adjusted odds ratio 0.66, 95% confidence interval 0.60-0.72), lower adjusted mortality among most of 6 subgroups determined by propensity to receive acute beta-blockers, and lower adjusted mortality in patients with and without signs of heart failure and in those <80 years and those > or =80 years old. CONCLUSIONS: The majority of NSTEMI patients receive acute beta-blocker therapy. Certain patient subgroups remain undertreated. Because treatment with acute beta-blockers was associated with improved clinical outcomes in nearly all patient subgroups assessed, broader use in patients with NSTEMI appears warranted.

Pay for performance, quality of care, and outcomes in acute myocardial infarction.

CONTEXT: Pay for performance has been promoted as a tool for improving quality of care. In 2003, the Centers for Medicare & Medicaid Services (CMS) launched the largest pay-for-performance pilot project to date in the United States, including indicators for acute myocardial infarction. OBJECTIVE: To determine if pay for performance was associated with either improved processes of care and outcomes or unintended consequences for acute myocardial infarction at hospitals participating in the CMS pilot project. DESIGN, SETTING, AND PARTICIPANTS: An observational, patient-level analysis of 105,383 patients with acute non-ST-segment elevation myocardial infarction enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) national quality-improvement initiative. Patients were treated between July 1, 2003, and June 30, 2006, at 54 hospitals in the CMS program and 446 control hospitals. MAIN OUTCOME MEASURES: The differences in the use of ACC/AHA class I guideline recommended therapies and in-hospital mortality between pay for performance and control hospitals. RESULTS: Among treatments subject to financial incentives, there was a slightly higher rate of improvement for 2 of 6 targeted therapies at pay-for-performance vs control hospitals (odds ratio [OR] comparing adherence scores from 2003 through 2006 at half-year intervals for aspirin at discharge, 1.31; 95% confidence interval [CI], 1.18-1.46 vs OR, 1.17; 95% CI, 1.12-1.21; P = .04) and for smoking cessation counseling (OR, 1.50; 95% CI, 1.29-1.73 vs OR, 1.28; 95% CI, 1.22-1.35; P = .05). There was no significant difference in a composite measure of the 6 CMS rewarded therapies between the 2 hospital groups (change in odds per half-year period of receiving CMS therapies: OR, 1.23; 95% CI, 1.15-1.30 vs OR, 1.17; 95% CI, 1.14-1.20; P = .16). For composite measures of acute myocardial infarction treatments not subject to incentives, rates of improvement were not significantly different (OR, 1.09; 95% CI, 1.05-1.14 vs OR, 1.08; 95% CI, 1.06-1.09; P = .49). Overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites (change in odds of in-hospital death per half-year period, 0.91; 95% CI, 0.84-0.99 vs 0.97; 95% CI, 0.94-0.99; P = .21). CONCLUSIONS: Among hospitals participating in a voluntary quality-improvement initiative, the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction. Conversely, we did not find evidence that pay for performance had an adverse association with improvement in processes of care that were not subject to financial incentives. Additional studies of pay for performance are needed to determine its optimal role in quality-improvement initiatives.

Heart failure with preserved left ventricular systolic function among patients with non-ST-segment elevation acute coronary syndromes.

Previous studies of non-ST-segment elevation acute coronary syndromes (NSTE ACSs) complicated by heart failure (HF) have focused primarily on patients with left ventricular systolic dysfunction defined by an ejection fraction (EF) <40%. Little is known about HF with preserved systolic function (EF > or =40%) in the NSTE ACS population. We identified high-risk patients with NSTE ACS (ischemic electrocardiographic changes and/or positive cardiac markers) from the CRUSADE quality improvement initiative who had an EF recorded and who had information on HF status. Management and outcomes were analyzed and compared based on the presence or absence of HF and whether left ventricular EF was > or =40%. Of 94,558 patients with NSTE ACS, 21,561 (22.8%) presented with signs of HF, and most had HF with preserved systolic function (n = 11,860, 55%). Mortality rates were 10.7% for HF/systolic dysfunction, 5.8% for HF/preserved systolic function, 5.7% for no HF/systolic dysfunction, and 1.5% for no HF/preserved systolic function. Use of guideline-recommended medical therapies and interventions was frequently significantly lower in those with HF regardless of EF compared with those without HF, except for use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. In conclusion, NSTE ACS complicated by HF with preserved systolic function is common and associated with a 2.3-fold higher mortality compared with NSTE ACS without HF or systolic dysfunction. Guideline-recommended therapies and interventions are under-utilized in patients with NSTE ACS and HF, with and without preserved systolic function, compared with those without HF.

Changes in patterns of coronary revascularization strategies for patients with acute coronary syndromes (from the CRUSADE Quality Improvement Initiative).

Since the introduction of drug-eluting stents (DESs), patterns of revascularization strategies for patients with non-ST-segment elevation acute coronary syndromes have not been assessed. We studied 82,924 patients from the CRUSADE Initiative who presented with non-ST-segment elevation acute coronary syndromes and underwent coronary angiography at 365 United States hospitals that had capabilities for surgical (coronary artery bypass grafting [CABG]) and percutaneous (percutaneous coronary intervention [PCI]) revascularization from January 2002 to June 2005. Temporal trends in the use of PCI, CABG, and medical management without revascularization were analyzed with respect to the introduction of DESs. In total, 73,577 patients (89%) had >50% stenosis in > or =1 coronary artery, and there was a significant increase in the use of PCI (vs CABG or medical management without revascularization) during the study period (38.3% vs 52.5%). By quarter 2 of 2005, 80% of patients who underwent PCI received a DES. In total, 18,462 of 25,068 patients (73.6%) with 3-vessel disease (3VD) underwent revascularization and use of CABG decreased for these patients (48.9% to 39.9%, p <0.001), whereas use of PCI increased (51.1% to 60.1%, p <0.001). Factors significantly associated with use of PCI for patients with 3VD who underwent any revascularization included previous PCI, previous CABG, cardiology inpatient care, care at an academic hospital, renal insufficiency, and previous congestive heart failure. In conclusion, coinciding with the introduction of DESs, there has been a significant increase in the use of PCI and, in those patients with 3VD, a decrease in the use of CABG with a shift toward increasing use of PCI. Long-term implications of this shift remain uncertain, especially in patients with 3VD.

Temporal trends in the use of early cardiac catheterization in patients with non-ST-segment elevation acute coronary syndromes (results from CRUSADE).

We evaluated temporal trends in the use of early (<48 hours) catheterization in patients with non-ST-segment elevation acute coronary syndromes with respect to baseline risk features since publication of the American College of Cardiology/American Heart Association guidelines, which include a class IA recommendation for an early invasive strategy for high-risk patients with non-ST-segment elevation acute coronary syndromes. Overall, we found that early catheterization use increased from 53% to 61% during the 3 years after the guidelines were released, but the increased use of early catheterization was highest (11%) in the group that was at lowest risk of predicted mortality, and it was lowest (6%) in the group at highest risk of predicted mortality who would potentially receive the most benefit from an aggressive treatment approach. In conclusion, despite the overall increase in the use of early catheterization, the gap between the use of an early invasive strategy in the highest and lowest risk patients remains large and tends to increase over time.

Acute clopidogrel use and outcomes in patients with non-ST-segment elevation acute coronary syndromes undergoing coronary artery bypass surgery.

OBJECTIVES: We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting (CABG) and examine the drug's impact on risks for postoperative transfusions among patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS). BACKGROUND: Adherence in community practice to American College of Cardiology/American Heart Association guidelines for clopidogrel use among NSTE ACS patients has not been previously characterized. METHODS: We evaluated 2,858 NSTE ACS patients undergoing CABG at 264 hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. We examined the patterns of acute clopidogrel therapy and its association with bleeding risks among those having "early" CABG < or =5 days and again among those having "late" surgery >5 days after catheterization. RESULTS: Within 24 h of admission, 852 patients (30%) received clopidogrel. In contrast to national guidelines, 87% of clopidogrel-treated patients underwent CABG < or =5 days after treatment. Among those receiving CABG within < or =5 days of last treatment, the use of clopidogrel was associated with a significant increase in blood transfusions (65.0% vs. 56.9%, adjusted odds ratio [OR] 1.36, 95% confidence interval [CI] 1.10 to 1.68) as well as the need for transfusion of > or =4 U of blood (27.7% vs. 18.4%, OR 1.70, 95% CI 1.32 to 2.19). In contrast, acute clopidogrel therapy was not associated with higher bleeding risks if CABG was delayed >5 days (adjusted OR 1.18, 95% CI 0.54 to 2.58). CONCLUSIONS: Despite guideline recommendations, the overwhelming majority of NSTE ACS patients treated with acute clopidogrel needing CABG have their surgery within < or =5 days of treatment. A failure to delay surgery is associated with increased blood transfusion requirements that must be weighed against the potential clinical and economic impacts of such delays.

Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE).

BACKGROUND: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce. METHODS: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative. RESULTS: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05). CONCLUSIONS: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

The obesity paradox in non-ST-segment elevation acute coronary syndromes: results from the 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.

BACKGROUND: Although obesity is a known risk factor for coronary artery disease, its impact on the presentation, treatment, and outcome of patients with acute coronary syndromes (ACS) has not been well studied. METHODS: Using data from the CRUSADE Initiative, we compared inhospital treatments and clinical outcomes of 80845 patients with high-risk non-ST-segment elevation (NSTE) ACS (positive cardiac markers and/or ischemic ST-segment changes) to determine whether there was an association with body mass index (BMI [kg/m2]). Patient weights were categorized according to World Health Organization classifications: Underweight (BMI <18.5), Normal range (BMI 18.5-24.9), Overweight (BMI 25-29.9), Obese Class I (BMI 30-34.9), Obese Class II (BMI 35-39.9), and Extremely Obese (BMI =40). RESULTS: Most (70.5%) of the CRUSADE patients were classified as overweight or obese; these patients were younger and more likely to present with comorbid conditions, including diabetes mellitus, hypertension, and hyperlipidemia. Medications given during the first 24 hours and invasive cardiac procedures recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were more commonly used in these patients. The incidence of death and death and reinfarction, adjusted for covariates, were generally lower in overweight and obese patients, compared with normal-weight patients, but higher in underweight and extremely obese patients. CONCLUSIONS: Most patients with NSTE ACS are overweight or obese. These patients receive more aggressive treatment, and, except for the extremely obese, have less adverse outcomes compared with underweight and normal-weight patients. Although obesity appears to be a risk factor for developing ACS at a younger age, it also appears to be associated with more aggressive ACS management and, ultimately, improved outcomes.

Clopidogrel to treat patients with non-ST-segment elevation acute coronary syndromes after hospital discharge.

BACKGROUND: Clopidogrel added to aspirin improved outcomes after hospitalization in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) in the Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) trial, regardless of in-hospital treatment approach. The American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for treating NSTE ACS thus recommend prescribing clopidogrel plus aspirin at discharge for all patients, not just for those undergoing percutaneous coronary intervention (PCI). METHODS: We studied 61 052 patients with high-risk NSTE ACS (defined as the presence of positive cardiac markers and/or ischemic ST-segment changes) from January 2002 through December 2003 at 461 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative. We evaluated temporal trends of clopidogrel use at discharge since the ACC/AHA 2002 Guidelines update and examined variables associated with clopidogrel use in patients who did not undergo PCI. RESULTS: A total of 34 319 patients (56.2%) received clopidogrel when they were discharged from the hospital. Among patients who did not undergo PCI, variables associated with receiving clopidogrel at discharge included prior PCI, coronary artery bypass grafting (CABG), stroke, or myocardial infarction; hypercholesterolemia; elevated cardiac markers; and cardiology inpatient care. By late 2003, 96.3% of patients who underwent PCI received clopidogrel at discharge, compared with 42.8% of patients who did not undergo cardiac catheterization and 23.5% of the patients who underwent CABG, although clopidogrel prescription at discharge increased in each of these treatment groups from 2002 to 2003. CONCLUSION: Since release of the ACC/AHA Guidelines recommendations for treatment of NSTE ACS, prescription of clopidogrel at hospital discharge in patients with NSTE ACS who are treated with medical therapy alone and in those who undergo CABG has increased, but most of these patients still do not receive clopidogrel at discharge.

Association between hospital process performance and outcomes among patients with acute coronary syndromes.

CONTEXT: Selected care processes are increasingly being used to measure hospital quality; however, data regarding the association between hospital process performance and outcomes are limited. OBJECTIVES: To evaluate contemporary care practices consistent with the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations, to examine how hospital performance varied among centers, to identify characteristics predictive of higher guideline adherence, and to assess whether hospitals' overall composite guideline adherence was associated with observed and risk-adjusted in-hospital mortality rates. DESIGN, SETTING, AND PARTICIPANTS: An observational analysis of hospital care in 350 academic and nonacademic US centers of 64,775 patients enrolled in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) National Quality Improvement Initiative between January 1, 2001, and September 30, 2003, presenting with chest pain and positive electrocardiographic changes or cardiac biomarkers consistent with non-ST-segment elevation acute coronary syndrome (ACS). MAIN OUTCOME MEASURES: Use of 9 ACC/AHA class I guideline-recommended treatments and the correlation among hospitals' use of individual care processes as well as overall composite adherence rates. RESULTS: Overall, the 9 ACC/AHA guideline-recommended treatments were adhered to in 74% of eligible instances. There was modest correlation in hospital performance among the individual ACS process metrics. However, composite adherence performance varied widely (median [interquartile range] composite adherence scores from lowest to highest hospital quartiles, 63% [59%-66%] vs 82% [80%-84%]). Composite guideline adherence rate was significantly associated with in-hospital mortality, with observed mortality rates decreasing from 6.31% for the lowest adherence quartile to 4.15% for the highest adherence quartile (P<.001). After risk adjustment, every 10% increase in composite adherence at a hospital was associated with an analogous 10% decrease in its patients' likelihood of in-hospital mortality (adjusted odds ratio, 0.90; 95% confidence interval, 0.84-0.97; P<.001). CONCLUSION: A significant association between care process and outcomes was found, supporting the use of broad, guideline-based performance metrics as a means of assessing and helping improve hospital quality.

Chronic kidney disease in patients with non-ST-segment elevation acute coronary syndromes.

PURPOSE: Chronic kidney disease has been linked to high mortality rates in patients with ST-segment elevation myocardial infarction but has not been well described for patients with non-ST-segment elevation acute coronary syndromes. We examined the treatment and outcomes of patients with both non-ST-segment elevation acute coronary syndromes and moderate to severe chronic kidney disease. SUBJECTS AND METHODS: We evaluated 45343 patients with non-ST-segment elevation acute coronary syndromes enrolled in the CRUSADE Quality Improvement Initiative and compared treatments and outcomes in patients with and without moderate to severe chronic kidney disease. RESULTS: Patients presenting with moderate to severe chronic kidney disease (n = 6560) were older, more often diabetic, and more likely to present with signs of congestive heart failure. Adherence to Class IA/IB guidelines recommendations was lower in patients with moderate to severe chronic kidney disease, who were significantly less likely to be treated with medications, undergo invasive cardiac procedures, and be given discharge counseling. Moderate to severe chronic kidney disease was associated with a 50% increased risk of mortality and a 70% increased likelihood of transfusion. Despite having a higher risk of adverse outcomes, patients with moderate to severe chronic kidney disease were treated less aggressively than patients with normal renal function. CONCLUSIONS: These findings suggest that, in patients with moderate to severe chronic kidney disease, safety concerns about adverse outcomes and the absence of trial data for this population may limit the use of guidelines-recommended therapies and interventions for non-ST-segment elevation acute coronary syndromes. The decreased use of discharge counseling in patients with moderate to severe chronic kidney disease and non-ST-segment elevation acute coronary syndromes may represent therapeutic nihilism.

Treatment disparities in the care of patients with and without diabetes presenting with non-ST-segment elevation acute coronary syndromes.

OBJECTIVE: The objective of this study was to characterize treatment patterns among patients with diabetes presenting with non-ST-segment elevation (NSTE) acute coronary syndromes (ACSs). RESEARCH DESIGN AND METHODS: We compared adherence to treatment recommendations from the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for NSTE ACS among 46,410 patients from 413 U.S. hospitals that were included in the Can Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) quality improvement initiative. Patients were stratified as nondiabetic, non-insulin-dependent diabetic (type 2 diabetic), and insulin-treated diabetic. RESULTS: Insulin-treated diabetic patients were less likely than nondiabetic patients to receive aspirin (adjusted odds ratio 0.83 [95% CI 0.74-0.93]), beta-blockers (0.89 [0.83-0.96]), heparin (0.90 [0.83-0.98]), and glycoprotein IIb/IIIa inhibitors (0.86 [0.79-0.93]). Type 2 diabetic patients were treated similarly to nondiabetic patients. After adjustment for differences in clinical characteristics, insulin-treated diabetic patients were significantly less likely than nondiabetic patients to receive cardiac catheterization within 48 h of presentation (0.80 [0.74-0.86]) or percutaneous coronary intervention (0.87 [0.82-0.94]). Compared with nondiabetic patients, insulin-treated diabetic and type 2 diabetic patients were more likely to undergo coronary artery bypass grafting (1.34 [1.21-1.49] and 1.35 [1.26-1.44]). In-hospital mortality rates were higher in insulin-treated diabetic (6.8%) and type 2 diabetic (5.4%) than in nondiabetic (4.4%) patients. CONCLUSIONS: Diabetic patients have a higher risk of mortality than nondiabetic patients, yet physicians adhere to the ACC/AHA NSTE ACS guidelines less often when treating diabetic patients, particularly insulin-treated diabetic patients. Increased use of guideline-recommended therapies and early invasive management strategies in diabetic patients may improve their outcomes.

The FIBROID Registry: symptom and quality-of-life status 1 year after therapy.

OBJECTIVES: To investigate the change in symptom severity and health-related quality of life among patients treated with uterine artery embolization for leiomyomata. METHODS: Using the Fibroid Registry for Outcomes Data (FIBROID), a multicenter, prospective, voluntary registry of patients undergoing uterine embolization for leiomyomata, we studied changes in symptom status, health-related quality of life, subsequent care, menstrual status, and satisfaction with outcome. Health-related quality-of-life and symptom status were measured using the Uterine Fibroid Symptom and Quality of Life, a leiomyoma-specific questionnaire. Summary statistics were used to describe the data set and multivariate analyses to determine predictors of outcome at 12 months. RESULTS: Of 2,112 eligible patients, follow-up data were obtained on 1,797 (85.1%) at 6 months and 1,701 (80.5%) at 12 months. At 12 months, the mean symptom score had improved from 58.61 to 19.23 (P < .001), whereas 5.47% of patients had no improvement. The mean health-related quality-of-life score improved from 46.95 to 86.68 (P < .001), whereas 5.0% did not improve. In the first year after embolization, hysterectomy was performed in 2.9% of patients, with 3.6% requiring gynecologic interventions by 6 months and an additional 5.9% between 6 and 12 months. Amenorrhea as a result of embolization occurred in 7.3% of patients. Of these, 86% were age 45 or older. Most patients were satisfied with their outcome (82% strongly agree or agree). Predictors of a greater symptom change score include smaller leiomyoma size, submucosal location, and presenting symptom of heavy menstrual bleeding. CONCLUSION: Uterine embolization results in substantial symptom improvement for most patients, with hysterectomy required in only 2.9% of patients in the first 12 months after therapy.