Coronary artery disease
Disparities in Management Patterns and Outcomes of Patients With Non–ST-Elevation Acute Coronary Syndrome With and Without a History of Cerebrovascular Disease

https://doi.org/10.1016/j.amjcard.2009.12.005Get rights and content

Cerebrovascular (CVD) disease is commonly associated with coronary artery disease and adversely affects outcome. The goal of the present study was to examine the temporal management patterns and outcomes in relation to previous CVD in a contemporary “real-world” spectrum of patients with acute coronary syndrome (ACS). From 1999 to 2008, 14,070 patients with non–ST-segment elevation ACS were recruited into the Canadian Acute Coronary Syndrome I (ACS I), ACS II, Global Registry of Acute Coronary Events (GRACE/GRACE2), and Canadian Registry of Acute Coronary Events (CANRACE) prospective multicenter registries. We stratified the study patients according to a history of CVD and compared their treatment and outcomes. Patients with a history of CVD were older, more likely to have pre-existing coronary artery disease, elevated creatinine, higher Killip class, and ST-segment deviation on admission. Despite presenting with greater GRACE risk scores (137 vs 117, p <0.001), patients with previous CVD were less likely to receive evidence-based antiplatelet and antithrombin therapies during the initial 24 hours of hospital admission. They were also less likely to undergo in-hospital coronary angiography and revascularization. These disparities in medical and invasive management were preserved temporally across all 4 registries. Patients with concomitant CVD had worse in-hospital outcomes. Previous CVD remained an independent predictor of in-hospital mortality (adjusted odds ratio 1.43, 95% confidence interval 1.06 to 1.92, p = 0.019) after adjusting for other powerful prognosticators in the GRACE risk score. However, it was independently associated with a lower use of in-hospital coronary angiography (adjusted odds ratio 0.70, 95% confidence interval 0.60 to 0.83, p <0.001). Underestimation of patient risk was the most common reason for not pursuing an invasive strategy. Revascularization was independently associated with lower 1-year mortality (adjusted odds ratio 0.48, 95% confidence interval 0.33 to 0.71, p <0.001), irrespective of a history of CVD. In conclusion, for patients presenting with non–ST-segment elevation-ACS, a history of CVD was independently associated with worse outcomes, which might have been, in part, because of the underuse of evidence-based medical and invasive therapies.

Section snippets

Methods

The Canadian ACS I, ACS II, GRACE/GRACE2 and CANRACE registries were prospective, multicenter, observational studies of patients admitted with ACS. The full details of the registry designs have been previously published.10, 11, 12, 13 In ACS I and ACS II, patients ≥18 years old presenting to hospital with suspected cardiac ischemia of onset of <24 hours were eligible for inclusion. In GRACE/GRACE2 and CANRACE, patients ≥18 years old with a presumptive diagnosis of ACS and at least one of the

Results

Table 1 lists the baseline demographic and clinical characteristics of the patients stratified by a history of CVD. A total of 14,070 patients with NSTE-ACS were recruited from 1999 to 2008, of whom 1,377 (9.8%) had a history of CVD. Patients with CVD were older and were more likely to have pre-existing CAD, diabetes, elevated creatinine, higher Killip class, and ST-segment deviation on admission. They also presented with greater GRACE risk scores.

Table 2 lists the use of antiplatelet and

Discussion

The key findings of the present multicenter, observational study of patients with NSTE-ACS were that compared to patients without previous CVD, those with previous CVD presented with higher risk features and had worse in-hospital and 1-year outcomes. These patients were also treated more conservatively with antiplatelet and antithrombin medications and were less likely to undergo in-hospital coronary angiography. In addition, these disparities in management patterns and outcomes persisted over

Acknowledgment

We are grateful to all the study investigators, coordinators, and patients who participated in the Canadian ACS, GRACE, and CANRACE registries.

References (30)

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Dr. Yan was supported by a New Investigator Award from the Heart and Stroke Foundation of Canada, Ottawa, Ontario, Canada. The Canadian ACS registries were sponsored by the Canadian Heart Research Centre, Toronto, Ontario, Canada (a federally incorporated not-for-profit academic research organization) and Key Pharmaceuticals, Division of Schering Canada, Inc., Mississauga, Ontario, Canada. GRACE and CANRACE were sponsored by an unrestricted grant from Sanofi-Aventis Canada Inc., Laval, Quebec, Canada and Bristol-Myers Squibb Canada, Montreal, Quebec, Canada.

The industrial sponsors had no involvement in the study conception or design; collection, analysis, and interpretation of data; writing, review, or approval of the report; or the decision to submit the report for publication.

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