pathway based approach to acute coronary syndrome · pathway based approach to acute coronary...
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Pathway Based Approach to Acute Pathway Based Approach to Acute Coronary SyndromeCoronary Syndrome
MunMun K. Hong, MDK. Hong, MDDirector, Cardiac Catheterization Laboratory and Director, Cardiac Catheterization Laboratory and
Interventional CardiologyInterventional CardiologySt. LukeSt. Luke’’ss--Roosevelt Hospital Center,Roosevelt Hospital Center,
New York, New YorkNew York, New York
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IntroductionIntroductionIn the United States approximately 8 million patients In the United States approximately 8 million patients annually present to the emergency departments with chest annually present to the emergency departments with chest pain or chest pain equivalent symptoms, which ultimately pain or chest pain equivalent symptoms, which ultimately results in 2.3 million hospitalizations for Acute Coronary results in 2.3 million hospitalizations for Acute Coronary Syndrome (ACS).Syndrome (ACS).1,2 1,2
Clinical guidelines for the management of ACS have Clinical guidelines for the management of ACS have consistently shown consistently shown a major gapa major gap between the national between the national guidelines and their application in the actual management of guidelines and their application in the actual management of patients with ACS.patients with ACS.33
1. Elliot Rapaport; Emerging Issues in Cardiology. Emerg Med 36(6):16-26, 20042. AHA Heart Disease and Stroke Statistics – 2006 Update. Circulation 2006;113:e85.33. Fonarow GC. Rev Cardiovasc Med. 2002;3:S2-S10.
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01234567
<65% 65-<75% 75-<80% 80%
InIn--hospital Mortality and hospital Mortality and Guideline AdherenceGuideline Adherence
5.6%4.9% 4.7%
3.6%
National Report. Available at: http://www.crusadeqi.com. Data collected from Nov, 2001– March, 2003.Adapted with permission from CRUSADE Web site, available at:http://www.crusadeqi.com. Accessed February 18, 2004.
n=47,148
In-h
ospi
tal M
orta
lity
(%)
Hospital Composite Adherence Quartiles (by Quartiles)
Improved Hospital Adherence
CRUSADE
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Other ObstaclesOther Obstacles
Cardiologists are not always the first physicians evaluating theCardiologists are not always the first physicians evaluating theACS patients.ACS patients.
Different specialists and even cardiologists may have different Different specialists and even cardiologists may have different approaches to the management of ACS patients.approaches to the management of ACS patients.
Actual daily care of ACS patients may be dependent on medical Actual daily care of ACS patients may be dependent on medical residents/cardiology fellows/nursing staff.residents/cardiology fellows/nursing staff.
Guidelines often do not incorporate the latest data.Guidelines often do not incorporate the latest data.
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Pathway
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Pathway
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Pathway
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Pathway
PrasugrelPrasugrel
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Pathway
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Pathway
BivalirudinBivalirudin
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Pathway
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Pathway
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Pathway
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Pathway
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Pathway
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Pathway
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Pathway
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Color Coded Admission Order SetColor Coded Admission Order Set
√√
√√
√√
√√
√√
√√
50
…pril, 20
….statin, 40
√√ √√
Initial treatment plan according to the PAIN letters
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Guided Discharge summariesGuided Discharge summaries
Patient discharge instructions
Including Smoking cessation
And exercise advise and
Referral for cardiac rehab if
Required.
√√
√√ √√
√√
√√
√√
√√√√√√
50
…pril, 20
…statin, 40
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Effect on Admission OrdersEffect on Admission Orders
P = 0.007
P =0.19 P < 0.0001P < 0.0001
5032 35
7554 54 62
45
020406080
100
Antiplatelets B-Blockers ACEi/ARBs Statins
%
PRE (n=215) POST (n=269)
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34 32 37
91
61 68 70
300
20406080
100
Antiplatelets B-Blockers ACEi/ARBs Statins
%
PRE (n=215) POST (n=269)
Effect on Discharge OrdersEffect on Discharge Orders
P < 0.0001P < 0.0001 P < 0.0001
P < 0.0001
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Effect on Discharge OrdersEffect on Discharge Orders
P < 0.0001P < 0.0001
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Mean Statin dose Mean Statin dose at Dischargeat Discharge
P < 0.0001P < 0.0001
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Treatment rates at Treatment rates at OneOne--Year FollowYear Follow--upup
Pre-ACAP Post-ACAP(n=215) (n=269) P
12-month follow-up: Statin 20% 84% 0.0001 LDL < 100 mg/dL 9% 47% 0.001 Beta-Blocker 21% 51% 0.001 Aspirin 36% 86% 0.001
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Clinical Events for the First Year Clinical Events for the First Year After DischargeAfter Discharge
0
10
20
40
PRE POST
28.5
15 16
5
13 *
5 *
22
1
Recurrent Angina
PCI/CABG Hospitalization Total Mortality
Even
tRat
es (%
)
36
19 *
ALL Events
* * P P < 0.05< 0.05
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LongLong--term Effect on Composite Endpointsterm Effect on Composite Endpoints
GROUP
PREPOST
0 2 4 6 8 10 12Follow-up Period
1009590858075706560
Sur
viva
l pro
babi
lity
(%)
HR = 0.42, HR = 0.42, (95% CI 0.19(95% CI 0.19--0.84),0.84),
P = 0.015P = 0.015
RRR = 60%
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ConclusionsConclusions
PathwayPathway--based approach to acute coronary syndrome based approach to acute coronary syndrome can provide a uniform management of patients and can provide a uniform management of patients and significantly improve the adherence to guidelines .significantly improve the adherence to guidelines .
This increased adherence to the guidelines can This increased adherence to the guidelines can improve the outcomes of patients with acute coronary improve the outcomes of patients with acute coronary syndrome. syndrome.