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Keith A. A. Fox, MB, ChB, FRCP; Philippe Gabriel Steg, MD; Kim A. Eagle, MD; Shaun G. Goodman, MD, MSc; Frederick A. Anderson, Jr, PhD; Christopher B. Granger, MD; Marcus D. Flather, MBBS, FRCP; Andrzej Budaj, MD, PhD; Ann Quill, MA; Joel M. Gore, MD; for the GRACE Investigators

JAMA. 2007;297:1892-1900.

Context  Randomized trials provide robust evidence for the impact of pharmacological and interventional treatments in patients with ST-segment elevation and non–ST-segment elevation acute coronary syndromes (NSTE ACS), but whether this translates to changes in clinical practice is unknown.

Objective  To determine whether changes in hospital management of patients with ST-segment elevation myocardial infarction (STEMI) and NSTE ACS are associated with improvements in clinical outcome.

Design, Setting, and Patients  In the Global Registry of Acute Coronary Events (GRACE), a multinational cohort study, 44 372 patients with an ACS were enrolled and followed up in 113 hospitals in 14 countries between July 1, 1999, and December 31, 2006.

Main Outcome Measures  Temporal trends in the use of evidence-based pharmacological and interventional therapies; patient outcomes (death, congestive heart failure, pulmonary edema, cardiogenic shock, stroke, myocardial infarction).

Results  Use of pharmacological medications increased over the study period (-blockers, statins, angiotensin-converting enzyme inhibitors, thienopyridines with or without percutaneous coronary intervention [PCI], glycoprotein IIb/IIIa inhibitors, low-molecular-weight heparin; all P<.001). Pharmacological reperfusion declined in patients with STEMI by –22 percentage points (95% confidence interval [CI], –27 to –17), whereas primary PCI increased by 37 percentage points (95% CI, 33-41). In patients with non-STEMI, rates of PCI increased markedly by 18 percentage points (95% CI, 15-20). Rates of congestive heart failure and pulmonary edema declined in both populations: STEMI, –9 percentage points (95% CI, –12 to –6) and NSTE ACS, –6.9 percentage points (95% CI, –8.4 to –4.7). In patients with STEMI, hospital deaths decreased by 18 percentage points (95% CI, –5.3 to –1.9) and cardiogenic shock by –24 percentage points (95% CI, –4.3 to –0.5). Risk-adjusted hospital deaths declined –0.7 percentage points (95% CI, –1.7 to 0.3) in NSTE ACS patients. Six-month follow-up rates declined among STEMI patients: stroke by –0.8 percentage points (95% CI, –1.7 to 0.1) and myocardial infarction by –2.8 percentage points (95% CI, –6.4 to 0.9). In NSTE ACS, 6-month death declined –1.6 percentage points (95% CI, –3.0 to –0.1) and stroke by 0.7 percentage points (95% CI, –1.4 to 0.1).

Conclusions  In this multinational observational study, improvements in the management of patients with ACS were associated with significant reductions in the rates of new heart failure and mortality and in rates of stroke and mycoardial infarction at 6 months.

Author Affiliations: Cardiovascular Research, Division of Medical and Radiological Sciences, The University of Edinburgh, Edinburgh, Scotland (Dr Fox); Hospital Bichat, Paris, France (Dr Steg); University of Michigan Health System, Ann Arbor (Dr Eagle); Canadian Heart Research Centre and Terrence Donnelly Heart Centre, Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario (Dr Goodman); University of Massachusetts Medical School, Worcester (Drs Anderson and Gore and Ms Quill); Royal Brompton & Harefield NHS Trust, London, England (Dr Flather); Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland (Dr Budaj); and Duke University Medical Center, Durham, NC (Dr Granger).

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