Medically Treated NSTE ACS Patients 'Forgotten'


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 paradoxically 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. Twenty-one percent 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, while 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 while 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 in contemporary cardiology 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 per 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 unanswered 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 in terms of the use of evidence-based medications? Part of the answer may lie in the fact that they tend to be older and have more comorbid conditions, Dr. Harrington observed.

“Should these CRUSADE results change practice today? I think absolutely they should because what they're telling us is we need to have an ongoing continuing emphasis on understanding evidence-based prescribing,” the cardiologist said. “We know we're doing a good job of caring for these patients, but we clearly can do better.”

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


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