Management of Patients with NSTE ACS Latest Insights from CRUSADE A National Quality Improvement Initiative Eric D. Peterson, MD, MPH Duke Clinical Research Institute Duke University Medical Center Durham, North Carolina Author Disclosures: Research and speaker support from Millennium, Schering Plough, BMS, Sanofi. Author Disclosures: Research and speaker support from Millennium, Schering Plough, BMS, Sanofi.

Goals for CRUSADE Improve Adherence to ACC/AHA Guidelines Improve Patient Outcomes n Aspirin l Clopidogrel n Beta Blocker n Heparin (UFH or LMWH) n GP IIb-IIIa Inhibitor l Cath/PCI n Aspirin n Clopidogrel n Beta Blocker n ACE Inhibitor n Statin/Lipid Lowering n Smoking Cessation n Cardiac Rehabilitation Acute Therapy Discharge Therapy 2002 ACC/AHA Guidelines Update

Last updated: 1/28/05 Sites Who Have Submitted = 486 AK (0) WA (8) OR (5) CA (36) ID (0) NV (3) MT (0) WY (0) CO (8) NM (2) ND (1) SD (2) NE (4) KS (3) OK (8) TX (17) MN (4) IA (4) MO (12) AR (4) LA (8) WI (5) MI (24) MI UT (1) AZ (9) HI (1) IL (15) IN (9) KY (8) TN (15) MS (7) AL (11) GA (15) FL (33) SC (6) NC (13) VA (16) OH (30) WV (3) PA (39) NY (36) MD (13) ME (1) VT (1) NH (2) NJ (10) MA (11) CT (8) DE (3) RI (1) DC (1) CRUSADE Site Distribution

CRUSADE DATA SUBMISSION From 486 Sites 130,735!

Representation of Elderly Community vs. RCT Population % Age >75 Decade GRACE VIGOUR RCT’s CRUSADE Lee, JAMA, 2001

Gender and Age: NSTE ACS Patient Age % of population

Age and Comorbid Illness % of population

Creatinine Clearance and Age VIGOUR Trials and CRUSADE Patient Age (Yrs) Median Creatinine Clearance*

Acute Medication Use – Q (Within 1st 24 hours in patients without contraindications) 96%96% 91%91%88%88% 46%46% 0% 20% 40% 60% 80% 100% ASAASA BetaBlockersBetaBlockersHeparin (LMW + UFH) Heparin GP IIb-IIIa Inhibitors Inhibitors Q CRUSADE data ClopidogrelClopidogrel 55%55%

Trends in Acute Therapy Adherence (Among Patients Without Contraindications) Quarter 1, 2002 through Quarter 4, 2004

82%82% 61%61% 0% 15% 30% 45% 60% 75% CathCath Cath < 48 hr PCIPCICABGCABG PCI < 48 hr Invasive Cardiac Procedures – Q (Among Patients Without Contraindications to Cath) 55%55% 52%52% 40%40% 0% 15% 30% 45% 60% 75% CathCath Cath < 48 hr PCIPCICABGCABG 12%12% PCI < 48 hr 90% Q CRUSADE Data

Trends in Invasive Procedure Use (Among Patients Without Contraindications to Cath) Quarter 1, 2002 through Quarter 4, 2004

The Train Speeds Up…. Faster Cardiac Catheterization* * Among those receiving cath

The Train Speeds Up…. Shrinking In-hospital ACS Care <3 Days 35% vs 47% <3 Days 35% vs 47%

Discharge Medication Use – Q (In patients without contraindications) *LVEF < 40%, CHF, DM, HTN # Known hyperlipidemia,  TC,  LDL 94% 91% 0% 20% 40% 60% 80% 100% ASABeta Blockers ACE- or ARB* 69% Any Lipid- Lowering Agent # 88% 72% Clopidogrel

Trends in Discharge Therapy (Among Patients Without Contraindications) Quarter 1, 2002 through Quarter 4, 2004

Overall Adherence Trends Over Time Quarter 1, 2002 – Quarter 3, 2004 Quarter 1, 2002 through Quarter 4, 2004

Need Right Drug but Also Right Dose Excessive Antithrombotic Dosing by Age Q1-Q CRUSADE data:

Consequences of Excessive Dosing: RBC Transfusions by Dose Excess RBC Transfusion (%)

Does it Matter? Mortality Rates by # of Acute Guideline Recommended Therapies Received % In-hospital Mortality Number of Recommended Therapies * Therapies = Acute Aspirin, Acute Beta-blockers, Acute Heparin, GP IIb/IIIa inhibitors, Cardiac Catheterization <48 hours Adjusted OR: 0.72 (0.68,0.76)

Mortality Rates by # of Acute Guideline Recommended Therapies Received by Age Group Age Group % In-hospital Mortality Number of Recommended Therapies * Therapies = Acute Aspirin, Acute Beta-blockers, Acute Heparin, GP IIb/IIIa inhibitors, Cardiac Catheterization <48 hours 0.71 (0.67,0.75) 0.79 (0.75,0.83) Adj. OR*

Mortality Rates by # of Acute Guideline Recommended Therapies Received by Risk Group Risk Group % In-hospital Mortality Number of Recommended Therapies * Therapies = Acute Aspirin, Acute Beta-blockers, Acute Heparin, GP IIb/IIIa inhibitors, Cardiac Catheterization <48 hours; Based on CRUSADE Risk Score

Latest Results in NSTE ACS in US Conclusions  Crusade continues to represent ‘real world’ NST ACS  Older patients  More comorbidity  Care for NSTE ACS is improving:  Continued progress in adherence to ACC/AHA Guidelines for both acute and discharge treatments  More early cath, leading to earlier discharge  Yet opportunities for improvement persist  Largest gaps: acute GP IIb/IIIa, D/C ACE, clopidogrel  “Right dosing” to reduce adverse events  And can lead to even better patient outcomes!