Utilization of Early Invasive Management Strategies for High-Risk Patients With Non–ST-Segment Elevation Acute Coronary Syndromes
Results From the CRUSADE Quality Improvement Initiative
- Deepak L. Bhatt, MD;
- Matthew T. Roe, MD, MHS;
- Eric D. Peterson, MD, MPH;
- Yun Li, MS;
- Anita Y. Chen, MS;
- Robert A. Harrington, MD;
- Adam B. Greenbaum, MD;
- Peter B. Berger, MD;
- Christopher P. Cannon, MD;
- David J. Cohen, MD, MSc;
- C. Michael Gibson, MS, MD;
- Jorge F. Saucedo, MD;
- Neal S. Kleiman, MD;
- Judith S. Hochman, MD;
- William E. Boden, MD;
- Ralph G. Brindis, MD, MPH;
- W. Frank Peacock, MD;
- Sidney C. Smith,, Jr, MD;
- Charles V. Pollack,, Jr, MD;
- W. Brian Gibler, MD;
- E. Magnus Ohman, MD;
- for the CRUSADE Investigators
- Author Affiliations: Cleveland Clinic Foundation, Cleveland, Ohio (Drs Bhatt and Peacock); Duke Clinical Research Institute, Durham, NC (Drs Roe, Peterson, Harrington, and Berger and Mss Li and Chen), Henry Ford Heart and Vascular Institute, Detroit, Mich (Dr Greenbaum); Brigham and Women’s Hospital, Boston, Mass (Dr Cannon); Beth Israel Deaconess Medical Center, Boston, Mass (Dr Cohen); TIMI Study Group, Harvard Medical School, Boston, Mass (Dr Gibson); University of Oklahoma Health Sciences Center, Oklahoma City (Dr Saucedo); Baylor College of Medicine, Houston, Tex (Dr Kleiman); New York University School of Medicine, NewYork, NY (Dr Hochman); University of Connecticut, Hartford (Dr Boden); Kaiser Permanente Health System, San Francisco, Calif (Dr Brindis); University of North Carolina at Chapel Hill (Drs Smith and Ohman); Pennsylvania Hospital, Philadelphia (Dr Pollack); and University of Cincinnati, Cincinnati, Ohio (Dr Gibler).
- Corresponding Author: Deepak L. Bhatt, MD, Cleveland Clinic Foundation, Department of Cardiovascular Medicine/Desk F25, 9500 Euclid Ave, Cleveland, OH 44195 (bhattd{at}ccf.org).
Abstract
Context The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of non–ST-segment elevation acute coronary syndromes (NSTE ACS) recommend early invasive management for high-risk patients, given the benefits with this approach demonstrated in randomized clinical trials.
Objectives To determine the use and predictors of early invasive management strategies (cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality.
Design, Setting, and Patients The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Quality Improvement Initiative evaluated care patterns and outcomes for 17 926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemic electrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 US hospitals with catheterization and revascularization facilities between March 2000 and September 2002.
Main Outcome Measures Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and in-hospital mortality.
Results Of the 17 926 patients analyzed, 8037 (44.8%) underwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to be treated with medications and interventions recommended by the ACC/AHA guidelines and had a lower risk of in-hospital mortality after adjusting for differences in clinical characteristics and after comparing propensity-matched pairs (2.5% vs 3.7%, P<.001).
Conclusions An early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy appears to be reserved for patients without significant comorbidities and those cared for by cardiologists and is associated with a lower risk of in-hospital mortality.
