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

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.

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

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.

Pathway

Pathway

Pathway

Pathway

PrasugrelPrasugrel

Pathway

Pathway

BivalirudinBivalirudin

Pathway

Pathway

Pathway

Pathway

Pathway

Pathway

Pathway

Color Coded Admission Order SetColor Coded Admission Order Set

√√

√√

√√

√√

√√

√√

50

…pril, 20

….statin, 40

√√ √√

Initial treatment plan according to the PAIN letters

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

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)

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

Effect on Discharge OrdersEffect on Discharge Orders

P < 0.0001P < 0.0001

Mean Statin dose Mean Statin dose at Dischargeat Discharge

P < 0.0001P < 0.0001

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

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

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%

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.