Disparities in management patterns and outcomes of patients with non-ST-elevation acute coronary syndrome with and without a history of cerebrovascular disease
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Authors
Lee, Tony C.Goodman, Shaun G.
Yan, Raymond T.
Grondin, Francois R.
Welsh, Robert C.
Rose, Barry
Gyenes, Gabor
Zimmerman, Rodney H.
Brossoit, Real
Saposnik, Gustavo
Graham, John J.
Yan, Andrew T.
Canadian Acute Coronary Syndromes I and II Investigators
Canadian Global Registry of Acute Coronary Events (GRACE/GRACE2) Investigators
Canadian Registry of Acute Coronary Events (CANRACE) Investigators
UMass Chan Affiliations
Center for Outcomes ResearchDocument Type
Journal ArticlePublication Date
2010-04-13Keywords
Acute Coronary Syndrome; Aged; Aged, 80 and over; Canada; Cerebrovascular Disorders; Coronary Angiography; Diagnosis, Differential; Early Diagnosis; *Electrocardiography; Female; Follow-Up Studies; Healthcare Disparities; Humans; Male; Middle Aged; Morbidity; *Myocardial Revascularization; Prospective Studies; Registries; Risk Factors; Survival Rate; *Thrombolytic Therapy; Time Factors; Treatment OutcomeHealth Services Research
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Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary "real-world" spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non-ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE(2)), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p <0.001), patients with previous CVD were less likely to receive evidence-based antiplatelet and antithrombin therapies during the initial 24 hours of hospital admission. They were also less likely to undergo in-hospital coronary angiography and revascularization. These disparities in medical and invasive management were preserved temporally across all 4 registries. Patients with concomitant CVD had worse in-hospital outcomes. Previous CVD remained an independent predictor of in-hospital mortality (adjusted odds ratio 1.43, 95% confidence interval 1.06 to 1.92, p = 0.019) after adjusting for other powerful prognosticators in the GRACE risk score. However, it was independently associated with a lower use of in-hospital coronary angiography (adjusted odds ratio 0.70, 95% confidence interval 0.60 to 0.83, p <0.001). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy. Revascularization was independently associated with lower 1-year mortality (adjusted odds ratio 0.48, 95% confidence interval 0.33 to 0.71, p <0.001), irrespective of a history of CVD. In conclusion, for patients presenting with non-ST-segment elevation-ACS, a history of CVD was independently associated with worse outcomes, which might have been, in part, because of the underuse of evidence-based medical and invasive therapies.Source
Am J Cardiol. 2010 Apr 15;105(8):1083-9. Epub 2010 Feb 20. Link to article on publisher's siteDOI
10.1016/j.amjcard.2009.12.005Permanent Link to this Item
http://hdl.handle.net/20.500.14038/27293PubMed ID
20381657Related Resources
Link to Article in PubMedae974a485f413a2113503eed53cd6c53
10.1016/j.amjcard.2009.12.005
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Management patterns of non-ST segment elevation acute coronary syndromes in relation to prior coronary revascularizationElbarasi, Esam; Goodman, Shaun G.; Yan, Raymond T.; Welsh, Robert C.; Kornder, Jan; Wong, Graham C.; Dery, Jean-Pierre; Anderson, Frederick A. Jr.; Gore, Joel M.; Fox, Keith A. A.; et al. (2010-01-28)BACKGROUND: Contemporary guidelines support an early invasive strategy for non-ST elevation acute coronary syndrome (NSTE-ACS) patients who had prior coronary revascularization. However, little is known about the management pattern of these patients in "real world." METHODS: We analyzed 3 consecutive Canadian registries (ACS I, ACS II, and Global Registry of Acute Coronary Events [GRACE]/expanded-GRACE) that recruited 12,483 NSTE-ACS patients from June 1999 to December 2007. We stratified the study population according to prior coronary revascularization status into 4 groups and compared their clinical characteristics, in-hospital use of medications, and cardiac procedures. RESULTS: Of the 12,483 NSTE-ACS patients, 71.2% had no prior revascularization, 14.2% had percutaneous coronary intervention (PCI) only, 9.5% had coronary artery bypass graft surgery (CABG) only, and 5% had both PCI and CABG. Compared to their counterparts without prior revascularization, patients with previous PCI and/or CABG were more likely to be male, to have diabetes, myocardial infarction, and heart failure but less likely to have ST-segment deviation or positive cardiac biomarker on presentation. Early use of evidence-based medications was higher among patients with previous PCI only and lower among patients with previous CABG only. After adjusting for possible confounders including GRACE risk score, prior PCI was independently associated with in-hospital use of cardiac catheterization (adjusted odds ratio [OR] 1.18, 95% CI 1.04-1.34, P = .008). In contrast, previous CABG was an independent negative predictor (adjusted OR .77, 95% CI 0.68-0.87, P < .001). There was no significant interaction (P = .93) between previous PCI and CABG. CONCLUSIONS: The NSTE-ACS patients with previous PCI were more likely to be treated invasively. Conversely, patients with prior CABG less frequently received invasive therapy. Future studies should determine the appropriateness of this treatment discrepancy.
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Has the frequency of bleeding changed over time for patients presenting with an acute coronary syndrome? The global registry of acute coronary eventsFox, Keith A. A.; Carruthers, Kathryn F.; Steg, Phillippe Gabriel; Avezum, Alvaro; Granger, Christopher B.; Montalescot, Gilles; Goodman, Shaun G.; Gore, Joel M.; Quill, Ann L.; Eagle, Kim A. (2010-03-17)AIMS: To determine whether changes in practice, over time, are associated with altered rates of major bleeding in acute coronary syndromes (ACS). METHODS AND RESULTS: Patients from the Global Registry of Acute Coronary Events were enrolled between 2000 and 2007. The main outcome measures were frequency of major bleeding, including haemorrhagic stroke, over time, after adjustment for patient characteristics, and impact of major bleeding on death and myocardial infarction. Of the 50 947 patients, 2.3% sustained a major bleed; almost half of these presented with ST-elevation ACS (44%, 513). Despite changes in antithrombotic therapy (increasing use of low molecular weight heparin, P < 0.0001), thienopyridines (P < 0.0001), and percutaneous coronary interventions (P < 0.0001), frequency of major bleeding for all ACS patients decreased (2.6 to 1.8%; P < 0.0001). Most decline was seen in ST-elevation ACS (2.9 to 2.1%, P = 0.02). The overall decline remained after adjustment for patient characteristics and treatments (P = 0.002, hazard ratio 0.94 per year, 95% confidence interval 0.91-0.98). Hospital characteristics were an independent predictor of bleeding (P < 0.0001). Patients who experienced major bleeding were at increased risk of death within 30 days from admission, even after adjustment for baseline variables. CONCLUSION: Despite increasing use of more intensive therapies, there was a decline in the rate of major bleeding associated with changes in clinical practice. However, individual hospital characteristics remain an important determinant of the frequency of major bleeding.
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Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE)Fox, Keith A. A.; Anderson, Frederick A. Jr.; Dabbous, Omar H.; Steg, Phillippe Gabriel; Lopez-Sendon, Jose; Van de Werf, Frans; Budaj, Andrzej; Gurfinkel, Enrique P.; Goodman, Shaun G.; Brieger, David (2007-02-08)OBJECTIVE: To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies. METHODS: GRACE (Global Registry of Acute Coronary Events) is a multinational, observational cohort study. This study involved 24,189 patients enrolled at 73 hospitals with on-site angiographic facilities. RESULTS: Overall, 32.5% of patients with a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (CABG; 4.0% in STEMI). The cumulative rate of in-hospital death rose correspondingly with the GRACE risk score (variables: age, Killip class, systolic blood pressure, ST segment deviation, cardiac arrest at admission, serum creatinine, raised cardiac markers, heart rate), from 1.2% in low-risk to 3.3% in medium-risk and 13.0% in high-risk patients (c statistic = 0.83). PCI procedures were more likely to be performed in low- (40% non-STEMI, 60% STEMI) than medium- (35%, 54%) or high-risk patients (25%, 41%). No such gradient was apparent for patients undergoing CABG. These findings were seen in STEMI and non-ST elevation ACS, in all geographical regions and irrespective of whether hospitals adopted low (4.2-33.7%, n = 7210 observations), medium (35.7-51.4%, n = 7913 observations) or high rates (52.6-77.0%, n = 8942 observations) of intervention. CONCLUSIONS: A risk-averse strategy to angiography appears to be widely adopted. Proceeding to PCI relates to referral practice and angiographic findings rather than the patient's risk status. Systematic and accurate risk stratification may allow higher-risk patients to be selected for revascularisation procedures, in contrast to current international practice.