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CRUSADE：
Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?
对不稳定性心绞痛患者进行快速危险分层可以减轻早期实施ACC/AHA指南的不良结果吗
Goals for CRUSADE   Improve Adherence to ACC/AHA Guidelines    Improve Patient Outcomes
Aspirin
Clopidogrel
Beta Blocker
Heparin (UFH or LMWH)
GP IIb-IIIa Inhibitor
Cath/PCI
Aspirin
Clopidogrel
Beta Blocker
ACE Inhibitor
Statin/Lipid Lowering
Smoking Cessation
Cardiac Rehabilitation
Acute Therapy
Discharge Therapy
2002 ACC/AHA Guidelines Update
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
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 – Q3 2004 (Within 1st 24 hours in patients without contraindications)
96%
91%
88%
46%
0%
20%
40%
60%
80%
100%
ASA
Beta
Blockers
Heparin
(LMW + UFH)
GP IIb-IIIa
Inhibitors
Q4 2004 CRUSADE data
Clopidogrel
55%
Trends in Acute Therapy Adherence (Among Patients Without Contraindications)
Quarter 1, 2002 through Quarter  4, 2004
82%
61%
0%
15%
30%
45%
60%
75%
Cath
Cath < 48 hr
PCI
CABG
PCI < 48 hr
Invasive Cardiac Procedures – Q4 2004 (Among Patients Without Contraindications to Cath)
55%
52%
40%
0%
15%
30%
45%
60%
75%
Cath
Cath < 48 hr
PCI
CABG
12%
PCI < 48 hr
90%
Q4 2004 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%
Discharge Medication Use – Q4 2004 (In patients without contraindications)
*LVEF < 40%, CHF, DM, HTN # Known hyperlipidemia, ? TC, ? LDL
94%
91%
0%
20%
40%
60%
80%
100%
ASA
Beta 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-Q2 2004 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!