Thursday, November 4, 2004

CRUSADE: Guidelines Still Not Being Followed for ACS
By Pat French

According to a new analysis from an ongoing national registry, people with chest pain and certain types of heart attacks still are not receiving the treatments recommended by practice guidelines, even though such treatments can save lives.

Since 2000, the American Heart Association and American College of Cardiology have had guidelines in place that outline the recommended treatment strategies for patients with unstable angina and heart attacks without ST-segment elevation on the electrocardiogram, collectively known as non-ST elevation acute coronary syndromes. The guidelines call for early diagnosis and aggressive treatment of these patients, which generally includes an angiogram; drugs to prevent blood clotting and to relieve pain; and angioplasty, stenting, or bypass surgery if appropriate.

How well U.S. hospitals are following these guidelines and how the outcomes of their patients may be affected as a result are at the heart of the CRUSADE* initiative, a collaboration of investigators across the United States. Since 2001, the CRUSADE project has collected information on more than 118,000 patients in hundreds of hospitals.

The new analysis, by Dr. Deepak Bhatt of the Cleveland Clinic and colleagues at the DCRI, the University of North Carolina at Chapel Hill, and investigators at 11 other centers, focused on the care of 17,926 high-risk CRUSADE patients treated at 248 U.S. hospitals able to perform angioplasty and bypass surgery. The results appear in the November 3 issue of the Journal of the American Medical Association.

The investigators measured whether the patients received the care recommended by the guidelines, whether having certain characteristics predicted the care they received, and whether their care related to their risk of dying in the hospital.

Less than half of the patients (44.8%) had an angiogram within 48 hours of arrival at the hospital. Those who did were younger, were more often white men, had fewer concurrent medical problems, were seen first by a cardiologist, and showed more damage to the heart muscle on an electrocardiogram or in laboratory tests.

Patients who would likely benefit most from aggressive treatment — the elderly, women, minorities, and sicker patients — appeared to be those least likely to receive it. The investigators note that the differences in treatment “... appear to be related to longstanding treatment biases.”

Patients who had an angiogram also were more likely to receive the other treatments recommended by the ACC/AHA guidelines. Not surprisingly, significantly fewer of them died while in the hospital compared with people who did not receive aggressive care — 2.5% versus 3.7%, respectively, after adjusting for baseline differences between the groups and the fact that treatment was not randomly assigned, as it would be in a clinical trial.

On a more encouraging note, the investigators did detect a slight increase in the use of aggressive treatment over the course of the study. This increase may reflect ongoing efforts to improve the care of patients with acute coronary syndromes, such as the AHA’s Get with the Guidelines program and the ACC’s Guidelines Applied in Practice project.

Authors of this article from the DCRI include Drs. Matt Roe, Eric Peterson, Bob Harrington, and Peter Berger and Ms. Anita Chen.

CRUSADE is funded by Millennium Pharmaceuticals Inc., Schering Corporation, and Bristol-Myers Squibb/Sanofi Pharmaceuticals Partnership. The DCRI owns the CRUSADE database and manages the data collection, analysis, and interpretation independently from these sponsors.

*CRUSADE = Can Rapid risk stratification of Unstable angina patients Suppress ADverse Event outcomes with early implementation of the ACC/AHA guidelines?