presenter disclosure information - capt · presenter disc jan kornder md frcjan kornder md, frc the...

Presenter Disc

Jan Kornder MD FRCJan Kornder MD, FRC

The following relationships

Over the last 2 years:

Advisory Boards: MODEST ( Less than

BMS, Lilly, Servier, Sanofi Aventis, an

Speaker Honoraria: MODEST ( Less th

Boehringer-Ingelheim, Astra Zeneca, L

R h R h A t Z M kResearch: Roche, Astra Zeneca, Merck

All Honoraria and consulting fee

closure Information

CPC FACCCPC, FACC

s exist related to this presentation:

n $5000 total):

nd Astra Zeneca

han $10000 total)

Lilly, Pfizer, Sanofi Aventis, BMS

k S h i BMS S fik-Schering, BMS, Sanofi

es donated to charity

Wh t iWhat is a

A registry is a systemati A registry is a systematipatients with a specific c

Registries do NOT test tdevice compared to anorecord real life data of wconditions or devicesconditions or devices

Registries can identify Chypothesis generating qanswer specific treatme

R i t ?Registry?

ic recording of data onic recording of data on condition or devicethe benefits of one drug or other or placebo, they what happens to pts with

CARE GAPS or provide questions, but do NOT nt questions

Wh t i lWhat is a cl

Biomedical or health-relatehuman beings that follow a

Interventional studies are t Interventional studies are tresearch subjects are assigto a treatment or other inteoutcomes are measured. outco es a e easu ed

Observational studies are tare observed and their outcthe investigators. g

i i l t i l?inical trial?

ed research studies in a pre-defined protocol. those in which thethose in which the gned by the investigator

ervention, and their

those in which individuals comes are measured by

Wh t i GWh t i GWhat is GWhat is G

Launched in 1999, The GLaunched in 1999, The GCoronary Events is an inCoronary Events is an ind i d t t k td i d t t k t

Launched in 1999, The GLaunched in 1999, The GCoronary Events is an inCoronary Events is an ind i d t t k td i d t t k tdesigned to track outcodesigned to track outcopresenting with acute copresenting with acute coincludingincluding myocardial infmyocardial inf

designed to track outcodesigned to track outcopresenting with acute copresenting with acute coincludingincluding myocardial infmyocardial infgg yyangina. angina.

GRACE includes hospitaGRACE includes hospitaSouth America EuropeSouth America Europe

gg yyangina. angina.

GRACE includes hospitaGRACE includes hospitaSouth America EuropeSouth America EuropeSouth America, Europe,South America, Europe,Zealand.Zealand.South America, Europe,South America, Europe,Zealand.Zealand.

GRACE?GRACE?GRACE?GRACE?

Global Registry of Acute Global Registry of Acute nternational database nternational database

f ti tf ti t

Global Registry of Acute Global Registry of Acute nternational database nternational database

f ti tf ti tmes of patients mes of patients oronary syndromes, oronary syndromes, farction or unstable farction or unstable

mes of patients mes of patients oronary syndromes, oronary syndromes, farction or unstable farction or unstable

als in North America, als in North America, Asia Australia and NewAsia Australia and New

als in North America, als in North America, Asia Australia and NewAsia Australia and New Asia, Australia and New Asia, Australia and New Asia, Australia and New Asia, Australia and New

MultinatMultinatMultinatMultinatArgentinaArgentina 7 sites7 sites

AustraliaAustralia 5 sites5 sites

AustriaAustria 5 sites5 sites

BelgiumBelgium 6 sites6 sitesgg

BrazilBrazil 7 sites7 sites

CanadaCanada 5 sites5 sites

FranceFrance 7 sites7 sites

Adapted fromAdapted from The GRACE IThe GRACE I

FranceFrance 7 sites7 sites

ional Site Networkional Site Networkional Site Networkional Site NetworkGermany Germany 5 sites5 sites

Italy Italy 5 sites5 sites

New Zealand New Zealand 2 sites2 sites

Poland Poland 6 sites6 sites

Spain Spain 3 sites3 sites

UK UK 4 sites4 sites

USAUSA 19 sites19 sites

Investigators Investigators Am Heart J Am Heart J 2001;141:1902001;141:190--99

USA USA 19 sites19 sites

What is GWhat is GWhat is GWhat is G Multinational, prospectivMultinational, prospectiv

spectrum of acute coronspectrum of acute coron Multinational, prospectivMultinational, prospectiv

spectrum of acute coronspectrum of acute coronspectrum of acute coronspectrum of acute coron

Observational databaseObservational database

spectrum of acute coronspectrum of acute coron

Observational databaseObservational databasepractices and patient oupractices and patient ou

14 countries in Europe, 14 countries in Europe,

practices and patient oupractices and patient ou

14 countries in Europe, 14 countries in Europe, America, Australia/New America, Australia/New

First 10 consecutive casFirst 10 consecutive cas

America, Australia/New America, Australia/New

First 10 consecutive casFirst 10 consecutive casFirst 10 consecutive casFirst 10 consecutive casqualifying symptoms qualifying symptoms plupluartery diseaseartery disease

First 10 consecutive casFirst 10 consecutive casqualifying symptoms qualifying symptoms plupluartery diseaseartery disease

The GRACE IThe GRACE I

GRACE?GRACE?GRACE?GRACE?ve registry of the entire ve registry of the entire nary syndromes (ACS)nary syndromes (ACS)ve registry of the entire ve registry of the entire nary syndromes (ACS)nary syndromes (ACS)nary syndromes (ACS)nary syndromes (ACS)

of clinical management of clinical management

nary syndromes (ACS)nary syndromes (ACS)

of clinical management of clinical management utcomes in ACSutcomes in ACS

North and South North and South

utcomes in ACSutcomes in ACS

North and South North and South ZealandZealand

ses per centre/month withses per centre/month with

ZealandZealand

ses per centre/month withses per centre/month withses per centre/month with ses per centre/month with usus evidence of coronary evidence of coronary ses per centre/month with ses per centre/month with usus evidence of coronary evidence of coronary

nvestigators nvestigators Am Heart J Am Heart J 2001;141:1902001;141:190--99

ObjecObjec

Identify opportunitiIdentify opportunitiquality of care for pquality of care for p

Identify opportunitiIdentify opportunitiquality of care for pquality of care for pq y pq y p

Describe diagnostiDescribe diagnostistrategies and hospstrategies and hosp

q y pq y p Describe diagnostiDescribe diagnosti

strategies and hospstrategies and hospstrategies and hospstrategies and hospassociated outcomassociated outcom

Develop hypotheseDevelop hypothese

strategies and hospstrategies and hospassociated outcomassociated outcom

Develop hypotheseDevelop hypothese Develop hypotheseDevelop hypotheseresearchresearch

Develop hypotheseDevelop hypotheseresearchresearch

ctivesctives

ies to improve the ies to improve the patients with ACSpatients with ACSies to improve the ies to improve the patients with ACSpatients with ACSppc and treatment c and treatment pital and 6pital and 6--monthmonth

ppc and treatment c and treatment pital and 6pital and 6--monthmonthpital and 6pital and 6 month month

mesmeses for future clinicales for future clinical

pital and 6pital and 6 month month mesmeses for future clinicales for future clinicales for future clinical es for future clinical es for future clinical es for future clinical

Patient EnrPatient Enrat e tat e t

6000060000

8000080000Patients Enrolled

ents

ents 5000050000

6000060000 6 Month Follow-Up

r of P

atie

r of P

atie

2869928699

3844438444

27273000030000

4000040000

Num

beN

umbe

1154311543

19453194531324513245

20303203032000020000

3000030000

66896689

00

1000010000

19991999--20002000 20012001 20022002 20032003

rolment + Followrolment + Follow--Up*Up*o e t o oo e t o o UpUp6293662936

7035970359

46945469455545455454

43117431175044250442

5710457104

76187618

3530135301

Canada (n=4,161 + 3558)Canada (n=4,161 + 3558)

22--yr: yr: 66416641

* As of Aug 26/08* As of Aug 26/08

33 2005200520042004 20062006 20072007

What is ExpaWhat is ExpaWhat is ExpaWhat is Expa( GRA( GRA

From 2001 to 2007, 3From 2001 to 2007, 3suspected ACS weresuspected ACS were

From 2001 to 2007, 3From 2001 to 2007, 3suspected ACS weresuspected ACS wereppGRACE at 184 hospitGRACE at 184 hospit

The distribution of paThe distribution of pa

ppGRACE at 184 hospitGRACE at 184 hospit

The distribution of paThe distribution of pafollows: Asia 16.7%, follows: Asia 16.7%, Europe 28.5%, NorthEurope 28.5%, NorthS th A i 11 2%S th A i 11 2%

follows: Asia 16.7%, follows: Asia 16.7%, Europe 28.5%, NorthEurope 28.5%, NorthS th A i 11 2%S th A i 11 2%South America 11.2%South America 11.2%South America 11.2%South America 11.2%

anded Graceanded Graceanded Graceanded GraceACE 2)ACE 2)31,982 patients with a 31,982 patients with a e enrolled in expanded e enrolled in expanded 31,982 patients with a 31,982 patients with a e enrolled in expanded e enrolled in expanded pptals in 25 countriestals in 25 countriesatients was as atients was as

pptals in 25 countriestals in 25 countriesatients was as atients was as Australia 3.8%, Australia 3.8%,

h America 39.8%, and h America 39.8%, and %%

Australia 3.8%, Australia 3.8%, h America 39.8%, and h America 39.8%, and %%%. %. %. %.

Expanded GRAExpanded GRA

Diabetes Substudy

ECG SubstudyBiological Marker

MicrBiological Marker

Substudy

GoGo

ACE = GRACE 2ACE = GRACE 2184 Hospitals184 Hospitals25 Countries25 Countries4 page CRF4 page CRF

*6 Month Follow*6 Month Follow--UpUp

87 Hospitals87 Hospitals13 Countries13 Countries

≈50≈50--100 Patients/hospital100 Patients/hospital10,000 Patients/year10,000 Patients/year

8 page CRF8 page CRF6 Month Follow6 Month Follow--UpUppp

roparticle SubstudyLipid Substudy

Bleeding Substudy

* In Canada* In Canada

oodman et al oodman et al Am Heart JAm Heart J 2009;158:1932009;158:193--201201

GRACE EGRACE ECountryCountry Number of SitNumber of SitCountryCountry Number of SitNumber of SitAustraliaAustralia 99Austria Austria 55BangladeshBangladesh 11BrazilBrazil 66BrazilBrazil 66BulgariaBulgaria 2323CanadaCanada 4444ChinaChina 1414ColumbiaColumbia 33EcuadorEcuador 11El SalvadorEl Salvador 11GermanyGermany 2020GuatemalaGuatemala 22ItalyItaly 1414ItalyItaly 1414LatviaLatvia 11MexicoMexico 22PanamaPanama 11PeruPeru 11PolandPoland 1010PortugalPortugal 11RomaniaRomania 33UkraineUkraine 33U it d A b E i tU it d A b E i t 11United Arab EmiratesUnited Arab Emirates 11United StatesUnited States 1111UruguayUruguay 22VenezuelaVenezuela 55

ExpansionExpansion As of December 31, 2007As of December 31, 2007tes*tes* Number of PatientsNumber of Patientstes*tes* Number of PatientsNumber of Patients

1,2251,225533533100100671671671671398398

11,26511,2653,8093,8091,1571,1572712711818

2,2342,2349999

732732

184 Hospitals184 Hospitals

31,982 31,982 7327323713712552553030

100100

PatientsPatients

4,1594,159153153319319215215

1 4201 420

*Enrolled ≥1 non*Enrolled ≥1 non--transfertransfer--in ptin pt

1,4201,4201,4561,456

8181911911

GRACEGRACEMonday NovMonday Nov

GRACEGRACEMonday, NovMonday, Nov

30 countries30 countries30 countries30 countries■■ 30 countries30 countries■■ 247 hospitals247 hospitals

102 341 patients (G102 341 patients (G

■■ 30 countries30 countries■■ 247 hospitals247 hospitals

102 341 patients (G102 341 patients (G■■ 102,341 patients (G102,341 patients (G■■ 118 Published Abs118 Published Abs

114 P bli h d M114 P bli h d M

■■ 102,341 patients (G102,341 patients (G■■ 118 Published Abs118 Published Abs

114 P bli h d M114 P bli h d M■■ 114 Published Man114 Published Man■■ 114 Published Man114 Published Man

E StatusE Statusvember 1 2010vember 1 2010

E StatusE Statusvember 1, 2010 vember 1, 2010

GRACE + GRACEGRACE + GRACE22))GRACE + GRACEGRACE + GRACE22))GRACE + GRACEGRACE + GRACE22))stractsstracts

i ti t

GRACE + GRACEGRACE + GRACE22))stractsstracts

i ti tnuscriptsnuscriptsnuscriptsnuscripts

Global RegistryGlobal RegistryE t E t Events Events

British British ColumbiaColumbia

SaskatchewanSaskatchewan2 sites2 sites

sites 12 sites 12 n=2674n=2674 AlbertaAlberta

2 sites2 sitesn=345n=345

n=247n=247

y of Acute Coronary y of Acute Coronary i C d i C d

17,241 ACS patients from 55 sites17,241 ACS patients from 55 sites

in Canada in Canada, p, p

1999 (GRACE); 2004 (GRACE1999 (GRACE); 2004 (GRACE22) ) ––2007; 2008 (CANRACE)2007; 2008 (CANRACE)

NewfoundlandNewfoundland1 it1 it

Ontario Ontario Quebec Quebec New Brunswick 3 New Brunswick 3

1 site1 siteN=30N=30

Ontario Ontario 21 sites 21 sites n=7736n=7736

14 sites 14 sites n=3545n=3545

New Brunswick 3 New Brunswick 3 sitessites

n=849n=849

247 C247 CGRACEGRACEGRACEGRACE

3030

*30 countries = 16 GRACE*30 countries = 16 GRACE2 2 + 7 core GRACE + 7 + 7 core GRACE + 7

Core GRACE & Core GRACE & EE22 Study Sites inStudy Sites inEE22 Study Sites in Study Sites in 0 Countries*0 Countries*

both both

Registry ManRegistry ManF dF dFundFund

Expanded GRACE is spoExpanded GRACE is spogrant from grant from sanofisanofi--aventiaventi

th I t tith I t ti

Expanded GRACE is spoExpanded GRACE is spogrant from grant from sanofisanofi--aventiaventi

th I t tith I t tiserves as the Internationserves as the InternationCenter for GRACE and eCenter for GRACE and eserves as the Internationserves as the InternationCenter for GRACE and eCenter for GRACE and e

GRACE is supported by GRACE is supported by educational grant from educational grant from ssf O t R hf O t R h

GRACE is supported by GRACE is supported by educational grant from educational grant from ssf O t R hf O t R hfor Outcomes Researchfor Outcomes ResearchMassachusetts Medical Massachusetts Medical for Outcomes Researchfor Outcomes ResearchMassachusetts Medical Massachusetts Medical

agement and agement and dididingding

onsored by an educational onsored by an educational isis to the COR. The COR to the COR. The COR

l S i tifi C di til S i tifi C di ti

onsored by an educational onsored by an educational isis to the COR. The COR to the COR. The COR

l S i tifi C di til S i tifi C di tinal Scientific Coordinating nal Scientific Coordinating expanded GRACE. expanded GRACE. nal Scientific Coordinating nal Scientific Coordinating expanded GRACE. expanded GRACE.

an unrestricted an unrestricted sanofisanofi--aventisaventis to the Center to the Center

U i it fU i it f

an unrestricted an unrestricted sanofisanofi--aventisaventis to the Center to the Center

U i it fU i it f, University of , University of School. School. , University of , University of School. School.

Data ManData ManData ManData Man

Data were collected at each sData were collected at each susing a standardized CRF. using a standardized CRF.

Demographic characteristicsDemographic characteristics

Data were collected at each sData were collected at each susing a standardized CRF. using a standardized CRF.

Demographic characteristicsDemographic characteristics Demographic characteristicsDemographic characteristicssymptoms, duration of prehosymptoms, duration of prehoECG findings, treatment pracECG findings, treatment pracoutcome data were collectedoutcome data were collected

Demographic characteristicsDemographic characteristicssymptoms, duration of prehosymptoms, duration of prehoECG findings, treatment pracECG findings, treatment pracoutcome data were collectedoutcome data were collectedoutcome data were collectedoutcome data were collected

Standardized definitions of aStandardized definitions of aclinical diagnoses were usedclinical diagnoses were used

Completed CRFs were faxedCompleted CRFs were faxed

outcome data were collectedoutcome data were collected Standardized definitions of aStandardized definitions of a

clinical diagnoses were usedclinical diagnoses were used Completed CRFs were faxedCompleted CRFs were faxed Completed CRFs were faxed Completed CRFs were faxed

(Center for Outcomes Resear(Center for Outcomes ResearMassachusetts Medical SchoMassachusetts Medical Scho

alternatively data were enteralternatively data were enter

Completed CRFs were faxed Completed CRFs were faxed (Center for Outcomes Resear(Center for Outcomes ResearMassachusetts Medical SchoMassachusetts Medical Scho

alternatively data were enteralternatively data were enter alternatively, data were enteralternatively, data were enterCRF.CRF.

alternatively, data were enteralternatively, data were enterCRF.CRF.

nagementnagementnagementnagement

site by a trained coordinator site by a trained coordinator

s medical history presentings medical history presenting

site by a trained coordinator site by a trained coordinator

s medical history presentings medical history presentings, medical history, presenting s, medical history, presenting ospital delay, biochemical and ospital delay, biochemical and ctices, and a variety of hospital ctices, and a variety of hospital ..

s, medical history, presenting s, medical history, presenting ospital delay, biochemical and ospital delay, biochemical and ctices, and a variety of hospital ctices, and a variety of hospital ... .

all patientall patient--related variables and related variables and d. d.

to the data coordinating centerto the data coordinating center

. . all patientall patient--related variables and related variables and d. d.

to the data coordinating centerto the data coordinating centerto the data coordinating center to the data coordinating center rch [COR], University of rch [COR], University of ool, Worcester, MA); ool, Worcester, MA); red into an electronic Webred into an electronic Web--basedbased

to the data coordinating center to the data coordinating center rch [COR], University of rch [COR], University of ool, Worcester, MA); ool, Worcester, MA); red into an electronic Webred into an electronic Web--basedbasedred into an electronic, Webred into an electronic, Web--based based red into an electronic, Webred into an electronic, Web--based based

DATA RDATA RDATA ReporDATA Repor

Each hospital received aEach hospital received acenter's data as well as center's data as well as

t ' d llt ' d ll

Each hospital received aEach hospital received acenter's data as well as center's data as well as

t ' d llt ' d llcountry's and overall wocountry's and overall wobasis. basis.

The goal of expanded GThe goal of expanded G

country's and overall wocountry's and overall wobasis. basis.

The goal of expanded GThe goal of expanded G The goal of expanded GThe goal of expanded Gadditional hospitals withadditional hospitals withGRACE countries as weGRACE countries as wenumber of participatingnumber of participating

The goal of expanded GThe goal of expanded Gadditional hospitals withadditional hospitals withGRACE countries as weGRACE countries as wenumber of participatingnumber of participatingnumber of participating number of participating project and enroll approproject and enroll approper year per year

number of participating number of participating project and enroll approproject and enroll approper year per year

ti t Sitti t Sitrting to Sitesrting to Sites

a profile of its own a profile of its own a summary of its a summary of its

ld d t t lld d t t l

a profile of its own a profile of its own a summary of its a summary of its

ld d t t lld d t t lorld data on a quarterly orld data on a quarterly

RACE was to expand toRACE was to expand to

orld data on a quarterly orld data on a quarterly

RACE was to expand toRACE was to expand toRACE was to expand to RACE was to expand to hin participating main hin participating main ell as to increase the ell as to increase the

countries in the GRACEcountries in the GRACE

RACE was to expand to RACE was to expand to hin participating main hin participating main ell as to increase the ell as to increase the

countries in the GRACEcountries in the GRACEcountries in the GRACE countries in the GRACE oximately 5,000 patients oximately 5,000 patients

countries in the GRACE countries in the GRACE oximately 5,000 patients oximately 5,000 patients

Q 4 2008 FINAL DDATA 18

Q 4 2008 FINAL D 19DATA

PopulationPopulation--

Defined CommunityDefined CommunityIncludes all hospitaIncludes all hospita Includes all hospitaIncludes all hospitaresidents may seekresidents may seek

Ideally socioIdeally socio demodemo Ideally, socioIdeally, socio--demodemocharacteristics matccharacteristics matcas a wholeas a wholeas a wholeas a whole

SS--Based SitesBased Sites

yyals where communityals where communityals where community als where community k carek careographic and hospitalographic and hospitalographic and hospital ographic and hospital ch country or region ch country or region

RepresentRepresent

Convenience sampConvenience sampconsidered represeconsidered represehospitals in the reghospitals in the reg

Balance characteriBalance characteriacademic vs. commacademic vs. commpublic vs. private spublic vs. private s

SStative Sitestative Sites

ple of hospitals ple of hospitals entative of the entative of the gion/countrygion/countrystics such as size, stics such as size,

munity hospital type, munity hospital type, status, facilities, etc.status, facilities, etc.

C SC SCase SeleCase Sele

Select first ~10 qualifSelect first ~10 qualif Confirm inclusion/excConfirm inclusion/exc Patient consent for foPatient consent for fo Enroll patientEnroll patient Complete initial CRFComplete initial CRF Complete 6Complete 6--month fomonth fopp

SSection Strategyection Strategy

fying cases in each monthfying cases in each monthclusion criteriaclusion criteriaollowollow--upup

llowllow--up CRFup CRFpp

Wh t i CWhat is a C

A CARE GAP is the d A CARE GAP is the doptimal therapy as strials and the actualtrials and the actual Hospital

CARE GAP?CARE GAP?

difference betweendifference between uggested by clinical care given at YOURcare given at YOUR

Optimal ACSOptimal ACS ManagemenManagemen

ACACGRACEGRACEQQ OptimaOptima

-- CurreCurreCC

Quarterly Quarterly feedback feedback reportsreports CareCare

IntervenIntervenContinuous Continuous

reportsreports

close Caclose Ca

PatientPatient

QualityQualityImprovementImprovement

Patient Patient OutcomesOutcomes

GRACEGRACEEvaluEvaluFollowFollow--up dataup data

nt: Closing the Care Gapnt: Closing the Care Gap

CSCSEvidenceEvidence--based based

al Careal Carentnt CareCareGG

de cede ce basedbasedguidelinesguidelines

GRACEGRACE DataDatae Gape Gap GRACEGRACE DataData

ntion to ntion to HospitalHospital--level level activitiesactivities

are Gapare Gap

HospitalHospital

activitiesactivities

HospitalHospitalResourcesResources

uationuation

Goodman et al Goodman et al Am Heart JAm Heart J 2009;2009;

JAMAJAMA 2007;297:18922007;297:1892--19001900

Wednesday, Wednesday, May 2nd 2007May 2nd 2007May 2nd, 2007 May 2nd, 2007

Edition of Edition of USA TODAY USA TODAY

GRACE RiskGRACE Risk6060

% of Patients% of Patients

Ri k F tRi k F t

InIn--HospitaHospita

4040

5050Risk FactorRisk FactorAgeAgeDiabetesDiabetesHypertensionHypertension

C SC S

3030

4040ypyp

Heart rate (per 30 beat/min Heart rate (per 30 beat/min ))Systolic BP (per 20 mm Hg Systolic BP (per 20 mm Hg ))Killip Class (per Killip Class (per in class)in class)Cardiac ArrestCardiac Arrest

2020Cardiac ArrestCardiac ArrestInitial Cardiac Marker +Initial Cardiac Marker +Initial Creatinine (per 88.4 µmol/L Initial Creatinine (per 88.4 µmol/L ))STST--segment deviationsegment deviation

0.30.3 0.40.4 0.60.6 0.80.8 1.11.1 1.61.6 2.12.1 2.92.93.93.900 0.20.2

1010Download PDA versDownload PDA vers

umassmed.org/gumassmed.org/g

GraGra

≤60≤60 7070 8080 9090 100100 110110 120120 130130 140140 150150Risk ScoreRisk Score

g gg g

k Score For All k Score For All ACSACS

11 38911 389

al Mortalityal Mortality

4444

5252Statistic = 0.84Statistic = 0.84 n=11,389n=11,389

2929

3636

4444

13131818

23232929

99 5.45.4 7.37.3 9.89.81313

ion at www.outcomesion at www.outcomes--grace/acs risk.cfmgrace/acs risk.cfm

anger et al anger et al Arch Int MedArch Int Med 2003;163:23452003;163:2345--5353

00 160160 170170 180180 190190 200200 210210 220220 230230 240240≥250≥250e (Points)e (Points)

g _g _

TrenTrenR fR f

5050 % of Patients% of PatientsReperfuReperfu

33

4040

2020

262633

2020

3030

1515

1010

2020

Primary PCI (nPrimary PCI (n

00April 1999April 1999-- July 2000July 2000-- July 2001July 2001-- JulyJuly

* Including non* Including non--transfertransfer--in patients witin patients withrs of symptom onset eligibhrs of symptom onset eligib

April 1999April 1999--June 2000June 2000

July 2000July 2000--June 2001June 2001


JulyJulyJuneJune

nds in Acute nds in Acute i Thi Th

4444

usion Therapyusion Therapy

3131

37374040

4444

3131

n=3,235)n=3,235)

*Median Time:*Median Time:34 (2734 (27--62) min62) min80 (4580 (45--119) min119) min

2002 2002-- July 2003July 2003-- July 2004July 2004-- July 2005July 2005--

th STEMI or presumed new LBBB th STEMI or presumed new LBBB ≤12 ≤12 ble for reperfusion therapyble for reperfusion therapy

2002 2002--e 2003e 2003



July 2005July 2005--June 2006*June 2006*

Eagle et al Eagle et al Eur Heart JEur Heart J 2008;29:6092008;29:609--1717

TrenTrenR fR f


33

4141 393936364040

2020

262633

222020

3030

1515

1010

2020Fibrinolysis (nFibrinolysis (nPrimary PCI (nPrimary PCI (n






JulyJulyJuneJune


4444

usion Therapyusion Therapy

3131

37374040

4444

3131

2727 24242020

1616n=2,887)n=2,887)n=3,235)n=3,235)




2002 2002--e 2003e 2003





TrenTrenR fR f


No ReperfusiNo Reperfusi

334040 3535

323233

4141 393936364040

No ReperfusiNo Reperfusi

2020

2626333232

222020

3030

1515

1010

2020Fibrinolysis (nFibrinolysis (nPrimary PCI (nPrimary PCI (n






JulyJulyJuneJune


4444

usion Therapyusion Therapyon Therapyon Therapy

3131

37374040

4444

3535 3333 3333

on Therapyon Therapy

3131 3333

2727 24242020

1616n=2,887)n=2,887)n=3,235)n=3,235)




2002 2002--e 2003e 2003





NoNoNSTEMI (nNSTEMI (n

100100 % of Patients% of PatientsTrends in Aspirin Trends in Aspirin

((

8080 9292 9191 90909292

9090 8888

6060

8888

2020

4040

00

2020 NSTEMINSTEMIUnstable AnginaUnstable Angina

0019991999--20012001 20022002 20032003 2020

onon--ST Elevation ACSST Elevation ACSn=28,431) + Unstable Angina (n=26,134)n=28,431) + Unstable Angina (n=26,134)

Use at AdmissionUse at Admission, ) g ( , ), ) g ( , )

9191 9494 949493939191 9292 91919393

004004 20052005 20062006 20072007

NoNoNSTEMI (nNSTEMI (n

100100 % of Patients% of PatientsTrends in Trends in ClopidogreClopidogre

((

8080NSTEMINSTEMIUnstable AnginaUnstable Angina

6060

2020

4040

2121

36364242

28283838

00

2020 21211818

0019991999--20012001 20022002 20032003 2020

* 1* 1stst 24 hours24 hours

onon--ST Elevation ACSST Elevation ACSn=28,431) + Unstable Angina (n=26,134)n=28,431) + Unstable Angina (n=26,134)

elel Use at Admission*Use at Admission*, ) g ( , ), ) g ( , )

48485858 6262

6868

52525757 5656

48484343

004004 20052005 20062006 20072007

Trends in CardiacTrends in Cardiac100100

% of Patients

8080

100100

NSTEMINSTEMIUnstable AnginaUnstable Angina

STEMI/LBBBSTEMI/LBBB

6060

Unstable AnginaUnstable Angina

2020

4040

20012001 20022002 20032003 2004200400

2020

20012001 20022002 20032003 20042004

c Catheterizationc Catheterization

n=17,241 (55 hospitals)

20052005 20062006 200820082007200720052005 20062006 2008200820072007

TrendsTrends100100

% of Patients

8080

100100

NSTEMINSTEMIUnstable AnginaUnstable Angina

STEMI/LBBBSTEMI/LBBB

6060

Unstable AnginaUnstable Angina

2020

4040

20012001 20022002 20032003 2004200400

2020

20012001 20022002 20032003 20042004

in PCI in PCI

n=17,241 (55 hospitals)

20052005 20062006 200820082007200720052005 20062006 2008200820072007

What are we doWhat are we doWhat are we doWhat are we doMemorial HospMemorial Hospto British Coluto British Coluand the Rest oand the Rest oand the Rest oand the Rest o

ing at Surreying at Surreying at Surrey ing at Surrey pital compared pital compared

umbia, Canada, umbia, Canada, of the World?of the World?of the World?of the World?

As of Q4 2007As of Q4 200711 and Q4 2008and Q4 200822

Presenting ECG* and CPresenting ECG* and CAs of Q4 2007As of Q4 2007 and Q4 2008and Q4 2008

N=93,092N=93,092

WorldWorld11

NonNon--ST ST MIMI31%31%

STST MIMI

N 93,092N 93,092

Unstable Unstable Angina Angina OtherOther

8%8% 29%29%

ST ST MIMI32%32%

8%8% 29%29%

242 sites 30 countries242 sites 30 countries242 sites, 30 countries242 sites, 30 countries

* based on site* based on site

Cardiac Marker StatusCardiac Marker StatusCanadaCanada22

N=17,144N=17,144


N 17,144N 17,144

Unstable Unstable Angina Angina

OtherOther14%14% 22%22%

ST ST MIMI24%24%

14%14%

55 sites55 sites

e interpretatione interpretation

55 sites55 sites

N=total; % as of Q4 2008N=total; % as of Q4 2008

Presenting ECG* and CPresenting ECG* and CN=total; % as of Q4 2008N=total; % as of Q4 2008

N=771N=771

Surrey Memorial HospitalSurrey Memorial Hospital


N 771N 771

Unstable Unstable Angina Angina

ST ST MIMI31%31%

OtherOther7%7%

OtherOther10%10%

* based on site interpretation * based on site interpretation

Cardiac Marker StatusCardiac Marker StatusBritish ColumbiaBritish Columbia

N=2,315N=2,315

Unstable Unstable A iA i


N 2,315N 2,315

Angina Angina

OtherOther22%22%

16%16%ST ST MIMI

21%21% 22%22%

12 sites12 sites

++ nonnon--ACS ACS finalfinal diagnosisdiagnosis

12 sites12 sites


Patient ChaPatient Cha


WorldWorld11

Median Age Median Age (years)(years)

n=93,092n=93,092

6666gg (y )(y )

>75 years (%)>75 years (%) 2727

Female (%)Female (%)

Prior MI (%)Prior MI (%)

3333

2929Prior MI (%)Prior MI (%) 2929

aracteristicsaracteristics

CanadaCanada22 SMHSMH22B.C.B.C.2222 n=17,144n=17,144

6767

n=771n=771

6161

n=2,315n=2,315

6666

3030 21212727

3535

3333

2727

2626

3131

24243333 26262424

N= total; % as of Q4 2007N= total; % as of Q4 200711 and Q4 2008and Q4 200822

InIn--Hospital Hospital N= total; % as of Q4 2007N= total; % as of Q4 2007 and Q4 2008and Q4 2008

WorldWorld11

n=93,092n=93,092(%)(%)CCnn

7070

3434

AngiographyAngiography

PCIPCI 3434

44

PCIPCI

CABGCABG

ProceduresProcedures

CanadaCanada22

n=17,144n=17,144SMHSMH22

n=771n=771B.C.B.C.22

n=2,315n=2,315

6767

3333

9494

88

8787

46463333

44

5858

--

4646

22


Selected AdmisSelected Admisin ST Elein ST Ele


in ST Elein ST Ele9595 9292

9797

8080

100100% of Patients% of Patients

9999

6060

8080

4040Surrey Memorial (n=265)Surrey Memorial (n=265)

00

2020 British Columbia (n=456)British Columbia (n=456)Canada (n=4,045)Canada (n=4,045)

00ASAASA CloClo

ssion Therapiesssion Therapiesvation MIvation MIvation MIvation MI

929284848484

3232

4646

2424

opidogrelopidogrel LMWH*LMWH** during hospitalization* during hospitalization

InIn--HospitaHospita3030 % of Patients% of Patients

25252222

2525

1616

2222

1515

2020

1616

1010

22 11

6633

5555 55

00

55

D thD th M di l M di l R t I h i R t I h i CCDeathDeath Myocardial Myocardial (re)infarction(re)infarction

Recurrent Ischemic Recurrent Ischemic SymptomsSymptoms

CCPulmPulm

EdEd


al Eventsal Events

British Columbia (n=2,315)British Columbia (n=2,315)22

Canada (n=17,144)Canada (n=17,144)22

World (n=89 383)World (n=89 383)11World (n 89,383)World (n 89,383)

10101212

22 22 0022 22 1144

22 11CHF/CHF/ C di i C di i M j Bl diM j Bl di StrokeStrokeCHF/CHF/monary monary demadema

Cardiogenic Cardiogenic ShockShock

Major BleedingMajor Bleeding

How Can GRACHow Can GRACHow Can GRACHow Can GRACQuality of Care Quality of Care

You need to know what yYou need to know what ycompare yourself to othecompare yourself to othei ti t

You need to know what yYou need to know what ycompare yourself to othecompare yourself to othei ti tinprovementinprovement

Quarterly reports of Quarterly reports of youryourkey performance indicatokey performance indicato

inprovementinprovement Quarterly reports of Quarterly reports of youryour

key performance indicatokey performance indicatokey performance indicatokey performance indicatorapid continuous quality rapid continuous quality

Networking with others inNetworking with others in

key performance indicatokey performance indicatorapid continuous quality rapid continuous quality

Networking with others inNetworking with others inggquality of ACS carequality of ACS care

Allows for development oAllows for development o

ggquality of ACS carequality of ACS care

Allows for development oAllows for development ofor other projectsfor other projectsfor other projectsfor other projects

E 2 Improve theE 2 Improve theE 2 Improve the E 2 Improve the at My Hospital?at My Hospital?

you are doing so you can you are doing so you can rs and strive for rs and strive for

you are doing so you can you are doing so you can rs and strive for rs and strive for

rr hospital data (including hospital data (including ors) allows a sequence ofors) allows a sequence ofrr hospital data (including hospital data (including ors) allows a sequence ofors) allows a sequence ofors) allows a sequence of ors) allows a sequence of improvement cyclesimprovement cycles

nterested in improving the nterested in improving the

ors) allows a sequence of ors) allows a sequence of improvement cyclesimprovement cycles

nterested in improving the nterested in improving the p gp g

of research infrastructure of research infrastructure

p gp g

of research infrastructure of research infrastructure

Management andManagement andP ti t B GRP ti t B GRPatients By GRPatients By GR

% of Patients% of PatientsInIn--Hospital Cath.Hospital Cath.

% of Patient% of PatientInIn--HospitaHospita

75.375.37575

% of Patients% of Patients9090 p<0.001 (3p<0.001 (3--group group

comparison)comparison) 7575

% of Patient% of Patient9090 p<0.001p<0.001

compcomp

52.552.54545

606069.869.8

4545

60604747

1515

3030

454535.135.1

1515

3030

00

1515

LowLowIntermedIntermedHighHigh

n=8063n=8063 n=8063n=8063 n=8063n=8063 00

1515

InterInterHighHighGRACE Risk GRACE Risk

LowLowIntermed.Intermed.HighHigh InterInterHighHigh

d Outcomes in ACSd Outcomes in ACSRACE Ri k SRACE Ri k SRACE Risk ScoreRACE Risk Scoress

al Revasc.al Revasc.% of Patients% of PatientsInIn--Hospital Death*Hospital Death*

ss1 (31 (3--group group parison)parison) 1515

% of Patients% of Patients1818

p<0.001 (trend)p<0.001 (trend)

* Not including unstable * Not including unstable angina patientsangina patients

55.655.67.97.9

1313

99

1212

33

66

3 33 3

LowLowrmed.rmed.1.21.200

33

LowLowIntermed.Intermed.HighHigh

3.33.3

Score TertilesScore TertilesLowLowrmed.rmed. LowLowIntermed.Intermed.HighHigh

Fox et al Fox et al Heart Heart 2007;93:1772007;93:177--82 82

% of Patients% of Patients100100

6 Month Follow6 Month Follow--Up SUp S

9191

7575

94948080

100100OverallOverallFrom DischargeFrom Discharge

nn~~

5050

757574746060

5050

2020

4040

00

2020

ASA/ASA/ Cl id lCl id l B tB tASA/ ASA/ AnticoagulantAnticoagulant

ClopidogrelClopidogrel BetaBeta

Selected MedicationsSelected Medications

5585858686 8787

9393~~6,4006,400

55 7171

Bl kBl k ACEi/ARBACEi/ARB St ti / Oth li idSt ti / Oth li ida Blockera Blocker ACEi/ARBACEi/ARB Statin/ Other lipid Statin/ Other lipid lowering agentlowering agent

6 month Follow u6 month Follow uCurrenCurren

100

60

80

40

60%

0

20

ACE/ARB Beta BlockACE/ARB Beta Block

SMH BC

Q 4 2008 FINAL D

up MEDs Maintenanceup MEDs Maintenanceppnt nt vsvs DC RXDC RX

ASA Statin ClopidrogelASA Statin Clopidrogel

Canada World

45DATA

6 month6 monthCC

100

60

80

100

40

60%

0

20

ACE/ARB Beta BlockACE/ARB Beta Block

SMH BC C

Q 4 2008 FINAL D

h Follow up MEDSh Follow up MEDSppCurrent RXCurrent RX

ASA Statin ClopidrogelASA Statin Clopidrogel

Canada World

46DATA

Leading andLeading andLeading andLeading andQuartileQuartileQuartileQuartile

100100 % of Patients% of Patients

95958686 9090

85858080

100100

67676060

2020

4040

00ASA <24 hrsASA <24 hrs BlockerBlocker <24 hrs<24 hrs HH

Adapted from Adapted from Peterson et al Peterson et al J Am J Am & Ohman et al & Ohman et al Am Heart Am Heart

d Lagging Hospital d Lagging Hospital d Lagging Hospital d Lagging Hospital es: Acute Carees: Acute Carees: Acute Carees: Acute Care

00 Leading CentersLeading CentersLagging CentersLagging Centers

4646 4848

6969 n=65,426n=65,426

4646 4848

2424 21212121

HeparinHeparin ClopidogrelClopidogrel GP IIb/IIIa GP IIb/IIIa I hibiI hibi

Coll CardiolColl Cardiol 2004;43(suppl.):406A2004;43(suppl.):406AJJ 2004;148(suppl.):S342004;148(suppl.):S34--9 9

InhibitorsInhibitors

PerformaPerformaPerformaPerformaRelationship betweeRelationship betweeRelationship betweeRelationship betwee

% of Patients% of PatientsInIn--hospitahospita

6 366 3666

88% of Patients% of Patients

p<0p<0n=64,775 with NSTEACS, 350 Un=64,775 with NSTEACS, 350 U

6.366.36

5.065.0644

66

22

00<66%<66% 6666--74%74%

Hospital Composite Hospital Composite p pp p* Use of 9 ACC/AHA Class I care indicators (ASA, ß* Use of 9 ACC/AHA Class I care indicators (ASA, ß--blocker, hblocker, h

clopidogrel, ACEi, lipidclopidogrel, ACEi, lipid--lowering med use) among eligible pts wlowering med use) among eligible pts w

ance Matters!ance Matters!ance Matters!ance Matters!en Process and Outcomeen Process and Outcomeen Process and Outcomeen Process and Outcomel Mortalityl Mortality

0.0010.001U.S. hospitals, Jan 2001U.S. hospitals, Jan 2001--Sept 2003 Sept 2003

4.634.63 4.174.17

7575--79%79% ≥≥80%80%Adherence* QuartilesAdherence* Quartiles

Peterson et al Peterson et al JAMAJAMA 2006;295:19122006;295:1912--2020

heparin, GP IIb/IIIa inhib. ≤24 hrs; discharge ASA, ßheparin, GP IIb/IIIa inhib. ≤24 hrs; discharge ASA, ß--blocker, blocker, without contraindications (adjusted for pt + hospital features)without contraindications (adjusted for pt + hospital features)

Factors AssoFactors AssoImproved GuidelImproved Guidel

Survey of 316 hospitals pSurvey of 316 hospitals p Survey of 316 hospitals pSurvey of 316 hospitals p Survey of 316 hospitals pSurvey of 316 hospitals p Correlation with guidelineCorrelation with guideline Independent predictors aIndependent predictors a

Survey of 316 hospitals pSurvey of 316 hospitals p Correlation with guidelineCorrelation with guideline Independent predictors aIndependent predictors a Independent predictors aIndependent predictors a

guideline adherence: guideline adherence: ModerateModerate--toto--strong adminstrong admin

Q lit I t (QI)Q lit I t (QI)

Independent predictors aIndependent predictors aguideline adherence: guideline adherence: ModerateModerate--toto--strong adminstrong admin

Q lit I t (QI)Q lit I t (QI)Quality Improvement (QI)Quality Improvement (QI) ModerateModerate--toto--strong collabstrong collab

physicians and hospital aphysicians and hospital a

Quality Improvement (QI)Quality Improvement (QI) ModerateModerate--toto--strong collabstrong collab

physicians and hospital aphysicians and hospital ap y pp y p Adequate nursing and phAdequate nursing and ph Use of a specified protocoUse of a specified protoco

l ith f ACSl ith f ACS

p y pp y p Adequate nursing and phAdequate nursing and ph Use of a specified protocoUse of a specified protoco

l ith f ACSl ith f ACSalgorithm for ACSalgorithm for ACSalgorithm for ACSalgorithm for ACS

ociated with ociated with lines Adherencelines Adherence

participating in CRUSADEparticipating in CRUSADEparticipating in CRUSADEparticipating in CRUSADEparticipating in CRUSADEparticipating in CRUSADEe adherencee adherence

associated with improvedassociated with improved

participating in CRUSADEparticipating in CRUSADEe adherencee adherence

associated with improvedassociated with improvedassociated with improved associated with improved

nistrative commitment to nistrative commitment to

associated with improved associated with improved

nistrative commitment to nistrative commitment to

boration between emergency boration between emergency administrationadministrationboration between emergency boration between emergency administrationadministrationarmacist supportarmacist supportolol--driven management driven management armacist supportarmacist supportolol--driven management driven management

Mehta et al Mehta et al Am Heart JAm Heart J 2006;152:6482006;152:648--6060

presenter disclosure information - capt · presenter disc jan kornder md frcjan kornder md, frc the...

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