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1
Acute Coronary Syndromes and Acute Coronary Syndromes and the Role of Critical Pathwaythe Role of Critical Pathway
Christopher Cannon, M.D.
Brigham and Women’s Hospital
Boston
2
Aspirin and Thrombolysis in Acute MI
13.2
10.7 10.4
8.0
0
5
10
15
% o
f P
atie
nts
% o
f P
atie
nts
ISIS-2. Lancet 1988; 2:349-60.
35 Day Mortality35 Day Mortality
PlaceboPlacebo Aspirin Aspirin SK SK Aspirin + SK Aspirin + SK
3
TIMI 2: Effect of Time to Treatment
0
2
4
6
8
10
<1 h1-2 h2-3 h3-4 h
% o
f P
atie
nts
% o
f P
atie
nts
TIMM, et al. TIMM, et al. Circulation. Circulation. 1991;84:II-230. 1991;84:II-230.
**PP=0.05=0.051 hour faster 1 hour faster
treatmenttreatment
==10 lives saved 10 lives saved per 1000 patients per 1000 patients treatedtreated
6 Week Mortality6 Week Mortality
3.2*3.2*3.73.7
5.25.26.26.2
62
31
TIMI 1:Reperfusion
Occluded arteries
0
20
40
60
80
% o
f P
atie
nts
t-PASK
*P<0.001
Improving Thrombolysis: t-PA vs. SK
TIMI Study NEJM 1985;312:397-401.
0
2
4
6
8
GUSTO 1:MortalityMortality
7.37.3
6.36.3
GUSTO Inv. NEJM 1993; 329:673-682.
*P<0.001
5
Thrombolysis vs. Primary Angioplasty
6.5
4.4
7.2
4.2
0
5
10
% o
f P
atie
nts
% o
f P
atie
nts
Weaver WD, JAMA 1997; 278:2093-2098. Schomig A, N Engl J Med 2000; 343:385-91
30 Day Mortality30 Day Mortality
Thrombolysis PTCA t-PA Stent + IIb/IIIaThrombolysis PTCA t-PA Stent + IIb/IIIa
6
Medical Treatment After MI
12.010.7
8.16.1
11.5
8.2
0
5
10
15
% o
f P
atie
nts
% o
f P
atie
nts
ISIS-1 Lancet 1986; 2:57-66; HOPE N Engl J Med 2000; 4S. Lancet 1994; 344:1383-1389.
Mortality During Follow-upMortality During Follow-up
ACUTE MI GUIDELINES 11/96
Drug Rx Peri MI: Meta-Analyses
Beta blocker during MI
Beta blocker post MI
ACEI during MI
ACEI post MI if LV dysfxn
Nitrates during MI
Ca++ blockers
Magnesium
Lidocaine
Class I Antiarrhythmics
Number RR Death p value
28,970
24,298
100,963
5,986
81,908
20,342
61,860
9,155
6,300
.87 (.77-.98)
.77 (.70-.84)
.94 (.89-.98)
.78 (.70-.86)
.94 (.90-.99)
1.04 (.95-1.14)
1.02 (.96-1.08)
1.38 (.98-1.95)
1.21 (1.01-1.44)
0.02
<0.001
0.006
<0.001
0.03
NS
NS
NS
0.04
NEJM 335:1662, 1996
8
Continuing Ischemia/Other Clinical High-Risk FeaturesContinuing Ischemia/Other Clinical High-Risk Features
• Bed rest + continuous Bed rest + continuous
ECG monitoringECG monitoring
• 0022 to maintain Sa0 to maintain Sa02 2 >90%>90%
• NTG IVNTG IV
-Blockers, oral -Blockers, oral
(+IV if high risk)(+IV if high risk)
• Morphine IV for painMorphine IV for pain
• IABP if ischemia or IABP if ischemia or BP BP
• ACEI for HTN or ACEI for HTN or LVEF LVEF
(possibly all patients)(possibly all patients)
Braunwald et al. Braunwald et al. J Am Coll Cardiol.J Am Coll Cardiol. 2000;36:970-1062. 2000;36:970-1062.
Class I Recommendations Class I Recommendations for Anti-Ischemic Therapyfor Anti-Ischemic TherapyUA/NSTEMI 9/00
9
AspirinAspirin++
IV heparinIV heparin++
IV platelet IV platelet GP IIb/IIIa antagonistGP IIb/IIIa antagonist
AspirinAspirin++
Subcutaneous Subcutaneous LMWHLMWH
ororIV heparinIV heparin
Possible Possible ACSACS
Likely/Definite Likely/Definite ACSACS
Definite ACSDefinite ACSWith Continuing Ischemia With Continuing Ischemia
or Other High-Risk Featuresor Other High-Risk Features†† or Planned PCIor Planned PCI
AspirinAspirin
* Clinical data on the combination of LMWH and platelet GP IIb/IIIa antagonists are lacking. * Clinical data on the combination of LMWH and platelet GP IIb/IIIa antagonists are lacking. Their combined use is not currently recommended.Their combined use is not currently recommended.†† High-risk features were previously listed; others include diabetes, recent MI, High-risk features were previously listed; others include diabetes, recent MI, and elevated cardiac TnT or Tnl.and elevated cardiac TnT or Tnl.
Braunwald et al. Braunwald et al. J Am Coll Cardiol.J Am Coll Cardiol. 2000;36:970-1062. 2000;36:970-1062.
Class I Recommendations for Class I Recommendations for Antithrombotic Therapy*Antithrombotic Therapy*UA/NSTEMI 9/00
10
Class I Recommendations: Class I Recommendations: Early Invasive StrategyEarly Invasive Strategy
1. Early invasive strategy in patients with UA/NSTEMI and any of the following high-risk indicators:a. Recurrent angina/ischemia at rest or with low-level activities
despite intensive anti-ischemic rxb. Recurrent angina/ischemia with CHF symptoms, S3 gallop,
pulmonary edema, worsening rales, or new or worsening MRc. High-risk findings on noninvasive stress testingd. Depressed LV systolic functione. Hemodynamic instabilityf. Sustained VTg. PCI within 6 monthsh. Prior CABG
2. In the absence of these, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization
Braunwald et al. Braunwald et al. J Am Coll Cardiol.J Am Coll Cardiol. 2000;36:970-1062. 2000;36:970-1062.
11
Class I Recommendations: Class I Recommendations: Risk Factor Modification Risk Factor Modification
1. Smoking cessation and achievement or maintenance of optimal weight, daily exercise, and diet
2. HMG-CoA reductase inhibitors for LDL >130 mg/dL
3. Lipid-lowering agent if LDL after diet is >100 mg/dL
4. Hypertension control to a blood pressure of >130/85 mm Hg
5. Tight control of hyperglycemia in diabetes
Braunwald et al. Braunwald et al. J Am Coll Cardiol.J Am Coll Cardiol. 2000;36:970-1062. 2000;36:970-1062.
UA/NSTEMI 9/00
Implementation of AHCPR Guidelines Implementation of AHCPR Guidelines for Unstable Angina in 1996:for Unstable Angina in 1996:
Unfortunate Differences Between Women and MenUnfortunate Differences Between Women and Men
Results from the GUARANTEE RegistryResults from the GUARANTEE Registry
ARANTEEARANTEEGUGU
6 Regions6 Regions 35 Hospitals35 Hospitals 2,948 Patients2,948 Patients
6 Regions6 Regions 35 Hospitals35 Hospitals 2,948 Patients2,948 Patients
GGlobal lobal UUnstable nstable AAngina ngina RRegistryegistry
ANANd d TTreatment reatment EEvaluationvaluation
ARANTEEARANTEEGUGU
No. PtsNo. Pts On AdmissionOn Admission
ASA (%)ASA (%)
Heparin (%)Heparin (%)
B-blockers (%)B-blockers (%)
At DischargeAt Discharge
ASA (or Warfarin) ASA (or Warfarin)
All of above (%)All of above (%)
17881788
8484
6666
5353
7777
3131
MenMen
1160 1160
8080
6060
4949
6969
2424
WomenWomen
0.0180.018
0.0010.001
0.0390.039
0.0010.001
0.0010.001
P valueP value
0.0160.016
0.0800.080
0.0860.086
0.0010.001
0.0070.007
AdjusteAdjusted d
P valueP value
Medical ManagementMedical ManagementARANTEEARANTEEGUGU
No. PtsNo. Pts
Cath (%)Cath (%)
PTCA (%)PTCA (%)
CABG (%)CABG (%)
In Pts Meeting AHCRP criteriaIn Pts Meeting AHCRP criteria
Cath (% done)Cath (% done)
CABG (% done)CABG (% done)
178817885353
1818
1010
5959
4646
MenMen
1160 1160 4444
1212
7%7%
5656
3636
WomenWomen
0.0010.001
0.0010.001
0.0020.002
0.150.15
0.160.16
P valueP value
0.0040.004
0.0170.017
0.0010.001
0.530.53
0.050.05
AdjusteAdjusted d
P valueP value
Catheterization / Catheterization / RevascularizationRevascularization
ARANTEEARANTEEGUGU
No. PtsNo. Pts On AdmissionOn Admission
ASA (%)ASA (%)
Heparin (%)Heparin (%)
B-blockers (%)B-blockers (%)
At DischargeAt Discharge
ASA (or Warfarin) ASA (or Warfarin)
All of above (%)All of above (%)
16381638
8383
6464
5050
7171
2828
Age <65Age <65
13091309
8181
6262
5252
7878
2828
Age Age >>6565
0.170.17
0.250.25
0.460.46
0.0010.001
0.920.92
P valueP value
0.240.24
0.190.19
0.680.68
0.0030.003
0.600.60
AdjusteAdjusted d
P valueP value
Medical ManagementMedical Management
AgeAge
ARANTEEARANTEEGUGU
No. PtsNo. Pts On AdmissionOn Admission
ASA (%)ASA (%)
Heparin (%)Heparin (%)
B-blockers (%)B-blockers (%)
At DischargeAt Discharge
ASA (or Warfarin) ASA (or Warfarin)
All of above (%)All of above (%)
26002600
8282
6161
4949
7373
2626
UAUA
300300
8787
8585
6363
8282
4545
NQWMINQWMI
0.0310.031
0.0010.001
0.0010.001
0.0010.001
0.0010.001
P valueP value
0.0690.069
0.0010.001
0.0010.001
0.0010.001
0.0010.001
AdjusteAdjusted d
P valueP value
Medical ManagementMedical Management
Non-Q wave MI vs. Unstable AnginaNon-Q wave MI vs. Unstable Angina
ARANTEEARANTEEGUGU
No. PtsNo. Pts On AdmissionOn Admission
ASAASA
HeparinHeparin
B-blockersB-blockers
16781678
8282
6363
4141
MenMen
1640 1640
7777
5050
3535
WomenWomen
17881788
8484
6666
5353
MenMen
1160 1160
8080
6060
4949
WomenWomen
Pre GuidelinePre Guideline
TIMI III RegistryTIMI III Registry
Stone PH et al. JAMA 1996;275:1104; Scirica 1999 AHJ
Post GuidelinePost Guideline
ARANTEEARANTEEGUGU
Comparing Pre- to Post-:Comparing Pre- to Post-: Men Men WomenWomenP values :P values : ASAASA 0.300.30 0.050.05
HeparinHeparin 0.130.13 0.0010.001B-blockerB-blocker 0.0010.001 0.0010.001
Aspirin within 24 hoursAspirin within 24 hoursAspirin within 24 hoursAspirin within 24 hours
0
20
40
60
80
100
0 8 16 24 32 40 48
Aspirin ( n = 189 )
No aspirin ( n = 33 )
0
20
40
60
80
100
0 8 16 24 32 40 48
Aspirin ( n = 189 )
No aspirin ( n = 33 )
Weeks post discharge
% s
urv
ival
94%
78%P = .002
Giugliano RP,et al. Arch Intern Med 2000;160.
Heparin within 24 hoursHeparin within 24 hoursHeparin within 24 hoursHeparin within 24 hours
0
20
40
60
80
100
0 8 16 24 32 40 48
Heparin ( n = 181 )
No heparin ( n = 47 )
0
20
40
60
80
100
0 8 16 24 32 40 48
Heparin ( n = 181 )
No heparin ( n = 47 )
Weeks post discharge
% s
urv
ival
93%
85%P = .06
Giugliano RP,et al. Arch Intern Med 2000;160.
Unadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year SurvivalUnadjusted One Year Survival
0
20
40
60
80
100
0 8 16 24 32 40 48
Guideline ( n = 189 )
Not guideline ( n = 86 )
0
20
40
60
80
100
0 8 16 24 32 40 48
Guideline ( n = 189 )
Not guideline ( n = 86 )
Weeks post discharge
Per
cen
t su
rviv
ing
95%
81%P = .0001
Giugliano RP,et al. Arch Intern Med 2000;160.
NRMI-1: Medical Therapy In-hospitalNRMI-1: Medical Therapy In-hospital
Thrombolysis No Thrombolysis
No. Pts 84477 156512
ASA (%) 84 63
Heparin (%) 97 56
IV nitro (%) 76 50
IV B-Blockers (%) 17 6
Oral B-Blockers (%) 36 29
Ca-Blockers (%) 29 42
Rogers WJ, et al. Circulation 1994;90:2103-2114.
0-30 mins34%
31-45 mins25%
46-60 mins15%
61-90 mins14%
>90 mins12%
0-30 mins34%
31-45 mins25%
46-60 mins15%
61-90 mins14%
>90 mins12%
N=84,423N=84,423
NRMI-2: Distribution of Door-to-Needle Times
40%40%Cannon CP ACC 2000
24
Baseline CharacteristicsBaseline Characteristics
0-300-30 31-6031-60 61-9061-90 >90>90 P valueNo. Pts 28,176 33,635 11,531 10,244
Age (mean) 61.2 63.5 65.1 65.7 <0.0001Female (%) 26 34 39 42 <0.0001Non-white (%) 13 14 16 19 <0.0001DM (%) 16 20 23 27 <0.0001Prior MI (%) 16 19 21 21 <0.0001Anterior (%) 32 34 37 41 <0.0001
HMO (%) 14 13 12 11 <0.0001Urban Hosp 87 88 87 86 0.0005Pre-hosp ECG 7 4 3 3 <0.0001Onset-door (hr) 1.4 1.7 1.9 2.0 <0.0001(Median)
Door-to-needle time (mins)Door-to-needle time (mins)
0.6
0.8
1
1.2
1.4
0-30 31-60 61-90 >90
Door-to-Needle Time (minutes)
MV
Ad
just
ed
Od
ds
of
De
ath
Cannon CP ACC 2000
NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality
N=28,624 33,867 11,616 10,316
P=0.01P=0.0001
P=NS
1.03
1.11
1.23
0.2
0.6
1
1.4
1.8
2.2
0-60 61-90 91-120 121-150 151-180 >180
Door-to-Balloon Time (minutes)
MV
Ad
just
ed
Od
ds
of
De
ath
P=0.01 P=0.0007 P=0.0003P=NSP=NS
1.14 1.15
1.41
1.62 1.61
N=2,230 5,734 6,616 4,461 2,627 5,412
NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality
Cannon CP, et al JAMA 2000;283:2941-2947.
8.2
21.224.4
16.5
9.7
20.0
0
5
10
15
20
25
30
0-60 61-90 91-120 121-150 151-180 >180
% o
f Pat
ient
s
8.2
21.224.4
16.5
9.7
20.0
0
5
10
15
20
25
30
0-60 61-90 91-120 121-150 151-180 >180
% o
f Pat
ient
s
N=27,080N=27,080
NRMI-2: Primary PCI Distribution of Door-to-Balloon times
Door-to-Balloon Time (minutes)
US News and World ReportUS News and World Report30-day mortality by hospital category*30-day mortality by hospital category*
0%
5%
10%
15%
20%
25%
30%
US News Invasive Non-invasive
Stars
* 25th, 50th and 75th percentile for each category
29
US News and World Report US News and World Report Aspirin in ideal candidatesAspirin in ideal candidates
0%
20%
40%
60%
80%
100%
Top-ranked Invasive Non-invasive
30
US News and World Report US News and World Report Beta-blockers in ideal candidatesBeta-blockers in ideal candidates
0%
20%
40%
60%
80%
100%
Top-ranked Invasive Non-invasive
30-day Mortality30-day MortalityUS News Top-ranked vs Other HospitalsUS News Top-ranked vs Other Hospitals
0.7
0.8
0.9
1
1.1
Adjusted* +ASA Adjusted* +BB Adjusted* +RPF
* Adjusted for patient, hospital and physician characteristics
Odds ratio
32
Quality implicationsQuality implications
– The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta-blockers
– Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta-blockers
EUROASPIRE II
European Action on Secondary and Primary
Prevention through Intervention to Reduce Events
Euro Heart Survey Programme European Society of Cardiology-ESC
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
% reaching goal* at interview among those using lipid-lowering medication
by center
EUROASPIRE
39
31
70
44
41
42
48
55
49
66
49
41
52
65
54
51
0 20 40 60 80 100
BEL/GHE
CZE/PP
FIN/KUO
FRA/LLRT
GER/MUNS
GRE/ATCI
HUN/BUD
IRE/DUB
ITA/TV
NET/ROT
POL/CRA
SLO/LJU
SPA/BAR
SWE/MAL
UK/HL
ALL
* total cholesterol < 5 mmol/l
Therapeutic control of total cholesterol at interview
European Society of Cardiology ESC
% aspirin/other anti-platelets at interview
by center EUROASPIRE
90
88
82
86
86
92
75
93
92
81
87
82
86
92
81
86
0 20 40 60 80 100
BEL/GHE
CZE/PP
FIN/KUO
FRA/LLRT
GER/MUNS
GRE/ATCI
HUN/BUD
IRE/DUB
ITA/TV
NET/ROT
POL/CRA
SLO/LJU
SPA/BAR
SWE/MAL
UK/HL
ALL
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
% beta-blockers at interviewby center
EUROASPIRE
7774
8860
6855
84
4761
4862
6647
6444
63
0 20 40 60 80 100
BEL/GHE
CZE/PP
FIN/KUO
FRA/LLRT
GER/MUNS
GRE/ATCI
HUN/BUD
IRE/DUB
ITA/TV
NET/ROT
POL/CRA
SLO/LJU
SPA/BAR
SWE/MAL
UK/HL
ALL
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
Conclusions
EUROASPIRE II
EUROASPIRE
A high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of prophylactic drug therapies is found in coronary patients across Europe
Considerable potential to raise the standard of preventive cardiology exists throughout Europe in order to reduce coronary morbidity and mortality
European Society of Cardiology ESC
Wood et al. Wood et al. Lancet Lancet 2001; 357: 995-10012001; 357: 995-1001
National Heart Attack
Alert Program (NHAAP)
CRITICAL PATHWAYS FOR THE TREATMENT OF
PATIENTS WITH ACUTE CORONARY SYNDROMES
39
Critical Pathways - DefinitionsCritical Pathways - Definitions
• Standardized protocols for care
• Strict definition
– Full list of all tasks, tracks variances
• Broader definition
– Includes clinical protocols (NHAAP 4D’s)
• Diagnostic pathways - Chest Pain Centers
• Treatment pathways - Thrombolysis
40
Goals of Critical PathwaysGoals of Critical Pathways
• Increase use of recommended medical therapies (e.g., aspirin)
• Decrease use of unnecessary tests.
• Decrease hospital length of stay
• Increase participation in clinical research
• Improve patient care and decrease costs.
41
Need and Rationale for Critical Need and Rationale for Critical PathwaysPathways
• Underutilization of recommended medications (e.g. Aspirin)
• Overutilization of procedures
• Length of stay, # ICU days
• Quality of care measures (door-to-drug, door-to-balloon times)
42
Development And Implementation Of Development And Implementation Of Critical PathwaysCritical Pathways
• Identify problems ( practice variation)
• Identify working committee/task force to develop path
• Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach.
• Implement pathway
• Collect and monitor data on pathway performance.
• Modify the pathway as needed to further improve performance.
43
Methods of Implementation of Methods of Implementation of PathwaysPathways
• Specific case manager for each Pt
– High compliance, high cost
• Standardized order sheets, Pocket guides
• “Championing” - Grand rounds
• Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107:324-31.)
44
Initial Treatment Strategy in Acute ST Elevation MI
Initial Treatment Strategy in Acute ST Elevation MI
Tlysis60%
1 PTCA9%
Non-Rep.31%
Tlysis65%
1 PTCA10%
Non-Rep.25%
All patients Pts. presenting < 12h
o
o
N=705N=837
TIMI 9TIMI 9RegistryRegistry
45
Goal: < 30 MinutesNHAAP Ann Emerg Med 1994;23:311-29.
46
35
40
45
50
55
60
65
Minutes (median)
NRMI 1 & 2 Trends:NRMI 1 & 2 Trends: Door to Drug (t-PA) IntervalDoor to Drug (t-PA) Interval
All Hospitals, t-PA-treated Patients (N = 241,757)
W. Rogers, personal communication
47
Speeding Time to Treatment: Brigham and Speeding Time to Treatment: Brigham and Women’s Hospital Acute MI Critical Pathway in EDWomen’s Hospital Acute MI Critical Pathway in ED
Pt. with Chest Pain. ED Arrival Time
Obtain ECG. Assess for ST Elevation
Assess for Contraindications to Thrombolysis:Active Bleeding Prior StrokeConfirmed BP > 190/110 Major Surgery <2 Mos.Other Major Illness (cancer, etc.)
Mix and Give Thrombolytic:
Double-Bolus r-PA
Primary PCI:1. Patient with high
stroke/bleeding risk2. Cardiogenic shock3. (All patients)
Door-to-Drug TimeGoal: <30 Mins
NO YES
10 mins
10 mins
10 mins
_ _ : _ _Door
_ _ : _ _Data
_ _ : _ _Decision
_ _ : _ _Drug
o
Cannon CP et al. J Thromb Thrombolysis 1994;1:27-34.
0
10
20
30
40
50
60
70
80
Jun-93
Jul-Sep93
Oct-Dec93
Jan-Mar94
Apr-Jun94
Jul-Sep94
Oct-Dec94
Jan-Mar95
Apr-Jun95
Jul-Sep95
Oct-Dec95
Min
utes
0
10
20
30
40
50
60
70
80
Jun-93
Jul-Sep93
Oct-Dec93
Jan-Mar94
Apr-Jun94
Jul-Sep94
Oct-Dec94
Jan-Mar95
Apr-Jun95
Jul-Sep95
Oct-Dec95
Min
utes
BWH Thrombolysis Critical Pathway: BWH Thrombolysis Critical Pathway: Effect on Door-to-Drug timesEffect on Door-to-Drug times
Door-to-Drug Time
Pre-Pre- Post-PathwayPost-Pathway Cannon CP, Clin Cardiol 1999;22:17-22
49
BWH Thrombolysis Critical Pathway: Initial BWH Thrombolysis Critical Pathway: Initial ExperienceExperience
0
20
40
60
80
100
120
Jun-Nov 20, 93 Nov 21, 93-June 94
July 94- Dec 94 Jan 95- June 95
Doo
r-to
-Nee
dle
Tim
e (M
ins) Women
Men
*P=0.013
Cannon CP, et al. Clin Cardiol 1999;22:17-22
BEFORE
50
2/94 - 1/95 2/95 - 7/95 P value
No Pts. 27 35
Door-Balloon Time
205+/- 130 97 +/- 57 0.02
Adverse Outcome
41% 17% 0.04
Death 26% 0% 0.004
Effect of CQI on Primary PCI Outcome
Caputo RP, Am J Cardiol 1997;79:1159-1164.
PAMI II: Early Discharge Critical Pathway for Low-PAMI II: Early Discharge Critical Pathway for Low-Risk MI Patients treated with Primary AngioplastyRisk MI Patients treated with Primary Angioplasty
6 month outcomes6 month outcomes Early D/CEarly D/C StandardStandard P valueP value(%)(%) (%)(%)
DeathDeath 0.80.8 0.40.4 NSNSMIMI 0.80.8 0.40.4 NSNSUnstable AnginaUnstable Angina 10.110.1 12.012.0 NSNSD/MI/UA/CHF/strokeD/MI/UA/CHF/stroke 15.215.2 17.517.5 NSNS
Length of stay (days)Length of stay (days) 4.24.2 7.17.1 p<0.001p<0.001Hospital CostsHospital Costs $9,658$9,658 $11,604$11,604 p=0.002p=0.002
++ 5,287 5,287 ++ 6,125 6,125
Early Discharge for Low Risk Patients: Randomized Trial Following Thrombolysis
Early D/CConventional
D/C
No. Pts. 40 40
Death 0 0
MI 0 5
Angina 3 8
Readmission 6 10
Topol, et al. NEJM 1988;318:1083-8.
53
BWH ED Checklist Orders for BWH ED Checklist Orders for UA/NSTEMIUA/NSTEMI
UA/NSTEMI
Hx. Good Story and/or + ECG, or + CKMB/TnI Hx MI, PCI/CABG
Tests CBC, CMP, PT/PTT CK-MB, TnI Lipid profile
Meds ASA 325mg chew Metoprolol IV/PO
Discuss with Cards B - Heparin IV + IIb/IIIa - Enoxaparin SQ - Cath Lab NTG PRN
54
Effect of Critical Pathway on Effect of Critical Pathway on Median Length of StayMedian Length of Stay
5
4
3 3
4
3
5
2 2
0
1
2
3
4
5
6
Feb(Pre)
July Sept. Oct. Nov.
Hos
pita
l Len
ght o
f Sta
y (D
ays)
Not On Path
On Path
55
CHAMP Program to improve CHAMP Program to improve Secondary PreventionSecondary Prevention
• Jan 1992- Dec 1995 N=256 pre- and 302 post
Pre-CHAMP post-CHAMPD/C 1 yr D/C 1 yr
ASA 78% 68% 92% 94%
B-blocker 12% 18% 61% 57%
ACE 4% 16% 56% 48%
Statin 6% 10% 86% 91%
LDL <100 6% 58%
Fonarow GC et al. Am J Cardiol 2001;87:819-822.Fonarow GC et al. Am J Cardiol 2001;87:819-822.
56
ConclusionsConclusions
• Critical pathways hold great promise to improve
– Quality of care,
– Clinical outcomes
– Cost-effectiveness
• Initial studies show better quality of care and suggest improved outcomes
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