This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on ISI (12)  • Contact me when this article is cited  Related Content  • Similar articles in this journal

Insights From the CRUSADE Initiative

Rajendra H. Mehta, MD, MS; Matthew T. Roe, MD, MHS; Anita Y. Chen, MS; Barbara L. Lytle, MS; Charles V. Pollack, Jr, MD, MA; Ralph G. Brindis, MD, MPH; Sidney C. Smith, Jr, MD; Robert A. Harrington, MD; Dan Fintel, MD; Elizabeth S. Fraulo, MS; Robert M. Califf, MD; W. Brian Gibler, MD; E. Magnus Ohman, MD; Eric D. Peterson, MD, MPH

Arch Intern Med. 2006;166:2027-2034.

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 -blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and -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.

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).

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Trends in Usage of Alternative Antiplatelet Therapy After Stroke and Transient Ischemic Attack
Hills and Johnston
Stroke 2008;39:1228-1232.
ABSTRACT | FULL TEXT  

Clinical benefit and practical use of fondaparinux in the invasive management of patients with acute coronary syndromes
Mehta
Eur Heart J Suppl 2008;10:C14-C21.
ABSTRACT | FULL TEXT  

Antiplatelet therapy in acute coronary syndromes
Gitt and Betriu
Eur Heart J Suppl 2008;10:A4-A12.
ABSTRACT | FULL TEXT  

Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology
Authors/Task Force Members et al.
Eur Heart J 2007;28:1598-1660.
FULL TEXT  

Managing acute coronary syndrome: Evidence-based approaches
Spinler
Am J Health Syst Pharm 2007;64:S14-S24.
ABSTRACT | FULL TEXT  

Improvement in Adherence to Guidelines for Acute Coronary Syndrome
JWatch Emergency Med. 2006;2006:4-4.
FULL TEXT