Mehta Rajendra H, Roe Matthew T, Chen Anita Y, Lytle Barbara L, Pollack Charles V, Brindis Ralph G, Smith Sidney C, Harrington Robert A, Fintel Dan, Fraulo Elizabeth S, Califf Robert M, Gibler W Brian, Ohman E Magnus, Peterson Eric D
Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA.
Arch Intern Med. 2006 Oct 9;166(18):2027-34. doi: 10.1001/archinte.166.18.2027.
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.
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.
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 beta-blockers by 12%; at hospital discharge, the use of antiplatelet agents increased by 3% and beta-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.
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.
国家卫生质量改进举措在多大程度上改变了非ST段抬高型急性冠状动脉综合征（NSTE ACS）患者报告的治疗差距尚不清楚。我们试图确定NSTE ACS基于指南治疗的近期趋势。
我们评估了2002年至2004年参加“不稳定型心绞痛患者快速风险分层能否通过早期实施ACC/AHA（美国心脏病学会/美国心脏协会）指南抑制不良结局”（CRUSADE）质量改进倡议的高危（心脏标志物阳性和/或缺血性ST段改变）NSTE ACS患者的治疗情况（11个日历季度共113595例患者）。我们分析了对指南推荐治疗的依从性，包括急性治疗期（就诊后<24小时）使用的药物、侵入性操作、住院结局以及出院治疗和干预措施。
在研究期间，每项I类指南推荐的使用以及对指南的总体依从性均显著改善（P<0.001）。在急性治疗环境中，抗血小板药物的使用增加了5%，β受体阻滞剂增加了12%；出院时，抗血小板药物的使用增加了3%，β受体阻滞剂增加了8%。急性治疗期肝素的使用增加了6%，主要是由于低分子量肝素的使用增加了9%。急性治疗期糖蛋白IIb/IIIa抑制剂的使用也增加了超过13%。出院时，氯吡格雷的使用增加了22%，降脂药物增加了11%，血管紧张素转换酶抑制剂增加了5%。虽然依从性有所改善，但许多患者在研究期末仍未接受100%的指定治疗。
自ACC/AHA关于NSTE ACS的指南首次发布后的4年里，参与CRUSADE的医院对I类推荐的依从性显著提高。然而，要最佳实施这些指南仍需要进一步改进。
