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Acute Coronary Treatment Veers Off Guidelines


 

NEW ORLEANS – A large proportion of patients with non-ST-elevation acute coronary syndrome get medical management without coronary angiography despite contemporary guidelines emphasizing an invasive strategy–yet this highest-mortality group of patients is least likely to receive evidence-based pharmacotherapy, Dr. Ezra A. Amsterdam reported at the annual scientific session of the American College of Cardiology.

He presented an analysis of CRUSADE quality improvement registry data involving 138,714 patients with non-ST-elevation acute coronary syndrome (NSTE ACS) treated at 547 U.S. hospitals during 2002-2005. Of those patients, 21% underwent cardiac catheterization without revascularization, 39.5% received percutaneous coronary revascularization, 10.9% had bypass surgery, and 28.6% received medical management only. During the study period, the use of solely medical management declined from 30.6% of all patients in 2002 to 25.6% in 2005, whereas percutaneous coronary intervention (PCI) rose from 36.2% to 42.1% in accord with current guideline recommendations.

The guidelines also call for routine use of certain evidence-based drugs in NSTE ACS patients regardless of whether they are managed invasively or noninvasively. But although there was an encouraging trend for greater use of these evidence-based medications over the years in medically managed patients, their usage remained significantly less than in patients who received PCI or bypass surgery (see chart), noted Dr. Amsterdam, professor of medicine and director of the cardiac care unit at the University of California, Davis.

In tandem with the more intensive use of evidence-based medications during the study period, unadjusted in-hospital mortality in patients managed solely medically declined from 8.0% to 6.6%, he added.

Discussant Dr. Robert A. Harrington described patients with NSTE ACS who are managed solely medically as “almost a forgotten population.”

“There's been so much emphasis placed on the role of the invasive management strategy and coronary revascularization that we often forget that upwards of one-third of patients presenting with an ACS will ultimately be treated medically,” said Dr. Harrington, director of cardiovascular clinical trials at the Duke Clinical Research Institute, Durham, N.C. With NSTE ACS patients accounting for more than 1 million hospital admissions a year in the United States, the CRUSADE evidence for often-suboptimal management of the large portion managed solely medically is an “incredibly important” concern, he added.

The key question raised by the CRUSADE findings is why these medically managed patients, who are at such high risk, are being treated less aggressively than those undergoing revascularization. Part of the answer may lie in the fact that they tend to be older and have more comorbid conditions, Dr. Harrington observed. “[CRUSADE results should] change practice today … because what they're telling us is we need to have an ongoing continuing emphasis on understanding evidence-based prescribing.”

CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines) was sponsored by Schering Plough Corp., Millenium Pharmaceuticals, Bristol-Myers Squibb, and Sanofi. As of January, it merged with the Genentech-sponsored National Registry for Myocardial Infarction to form the Acute Coronary Treatment and Intervention Outcomes Network registry.

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