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Original Investigation
October 9, 2006

Recent Trends in the Care of Patients With Non–ST-Segment Elevation Acute Coronary Syndromes: Insights From the CRUSADE Initiative

Author Affiliations

Author Affiliations: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (Drs Mehta, Roe, Harrington, Califf, Ohman, and Peterson and Mss Chen, Lytle, and Fraulo); Pennsylvania Hospital, University of Pennsylvania School of Medicine, Philadelphia (Dr Pollack); San Francisco Kaiser Permanente Hospital, San Francisco, Calif (Dr Brindis); University of North Carolina School of Medicine, Chapel Hill (Dr Smith); Northwestern University Feinberg School of Medicine, Chicago, Ill (Dr Fintel); and University of Cincinnati School of Medicine, Cincinnati, Ohio (Dr Gibler).

Arch Intern Med. 2006;166(18):2027-2034. doi:10.1001/archinte.166.18.2027

Background  The extent to which national health quality improvement initiatives have altered reported treatment gaps among patients with non–ST-segment elevation acute coronary syndromes (NSTE ACS) is unknown. We sought to determine recent trends in adherence to guideline-based therapies for NSTE ACS.

Methods  We evaluated the treatment of patients with high-risk (positive cardiac markers and/or ischemic ST-segment changes) NSTE ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA (American College of Cardiology/American Heart Association) Guidelines (CRUSADE) Quality Improvement Initiative from 2002 through 2004 (a total of 113 595 patients over 11 calendar quarters). We analyzed adherence to guideline-recommended therapies, including medications used in the acute care period (<24 hours after presentation), invasive procedures, in-hospital outcomes, and discharge therapies and interventions.

Results  The use of each class I guideline recommendation, as well as overall adherence to the guidelines, improved significantly (P<.001) during the study period. In the acute care setting, the use of antiplatelet agents increased by 5% and β-blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and β-blockers by 8%. Heparin use in the acute care period increased by 6%, largely owing to a 9% increase in the use of low-molecular-weight heparin. Use of glycoprotein IIb/IIIa inhibitors in the acute care period also increased by more than 13%. At discharge, clopidogrel use increased by 22%, lipid-lowering agents by 11%, and angiotensin-converting enzyme inhibitors by 5%. While adherence improved, many patients still failed to receive 100% indicated treatments at the end of the study period.

Conclusions  During the 4 years since the initial release of the ACC/AHA guidelines for NSTE ACS, adherence to class I recommendations has significantly improved among hospitals participating in CRUSADE. Still, further improvements are needed for optimal implementation of the these guidelines.