Antiplatelet Therapy in Patients with Unstable Angina and Non-ST-Segment-Elevation Myocardial Infarction: Findings from the CRUSADE National Quality Improvement Initiative

Michael B. Bottorff, Pharm.D.; Edith A. Nutescu, Pharm.D.; Sarah Spinler, Pharm.D.

Disclosures

Pharmacotherapy. 2007;27(8):1145-1152. 

In This Article

Mortality Rate

Cumulative data collected through the CRUSADE initiative indicate that the real-world in-hospital mortality rate associated with unstable angina and NSTEMI is 4.5%,[30] which is more than double the 7-day mortality rates of 1.5−1.9% recorded for ACS in contemporary large-scale clinical trials.[33,64,65] This finding is consistent with previous observations of trial versus nontrial mortality rates[36,66] and reflects the fact that clinical trial participation mandates close clinical observation and is therefore likely to influence care patterns. The CRUSADE data have been used to evaluate the influence of clinical trial enrollment on the quality of care for patients with unstable angina or NSTEMI. The findings suggest that trial participants are more likely to receive beneficial therapies and interventions throughout hospitalization than are nonparticipants (e.g., cardiac catheterization 84.5% vs 65.8%, p<0.0001; PCI 48.2% vs 36.3%, p<0.0001; bypass surgery 19.1% vs 11.3%, p<0.0001).[67] Significant predictors of trial participation included being male, lack of renal impairment, and lack of heart failure at presentation. These are factors that are associated with favorable outcomes, and preferential recruitment of such patients by trial investigators may contribute to a low on-trial mortality rate and limit the validity of trial results as they relate to the real-world setting.

Analysis of regional variation in the treatment and outcomes of 56,466 patients with unstable angina or NSTEMI from 310 hospitals with CABG surgery capability has been undertaken.[68] Significant differences in overall in-hospital mortality rates across the Northeast (3.5%), West (4.5%), Midwest (4.6%), and South (3.8%) were identified. After adjustment for clinical and treatment variables, mortality rates were found to be lower in the Northeast compared with that in the West (OR 1.40), Midwest (OR 1.42), and South (OR 1.33). These differences were unrelated to differences in the use of appropriate therapies or procedures, and further investigation of the cause of this regional variation is needed.

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