Christer Ohman - Cocuklar Icin Dunya Tarihi I - Tasbaltalar ve Piramitler.pdf
E. Magnus Ohman, MB, FRCPI, FESC, FACC Professor of Cardiovascular Medicine Director, Program for...
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Transcript of E. Magnus Ohman, MB, FRCPI, FESC, FACC Professor of Cardiovascular Medicine Director, Program for...
E. Magnus Ohman, MB, FRCPI, FESC, FACCProfessor of Cardiovascular Medicine
Director, Program for Advanced Coronary DiseaseDuke University Medical CenterDuke Clinical Research Institute
Durham, North Carolina
Evidence-Based Medicine Therapies in ACS: From Principles to Practice
Conflict of interest:Research grants -
• Berlex, Sanofi-Aventis, Schering-Plough, The Medicine Company, Bristol Meyer Squibb, CVT
Therapeutics, and Eli LillyStock ownership -
• Medtronic, SavacorConsultant -
• Northpointe Domain, Liposcience, Abiomed, Datascope, and Inovise Medical
Evidence-Based Medicine Therapies in ACS; From Principles to Practice
Evidence-Based Medicine Therapies in ACS; From Principles to Practice
Changes in Health Care Systems: Moving From the 20th to the 21st Century
Changes in Health Care Systems: Moving From the 20th to the 21st Century
Provider-centered Price-driven Care decisions widely
varying Fragmented care Little quality
measurement Persistent escalating
costs
Provider-centered Price-driven Care decisions widely
varying Fragmented care Little quality
measurement Persistent escalating
costs
Patient-centered Value-driven Evidence-based care
Coordinated care Ubiquitous quality
measurement Overall cost decline
Patient-centered Value-driven Evidence-based care
Coordinated care Ubiquitous quality
measurement Overall cost decline
2020thth Century Century2020thth Century Century 2121stst Century Century2121stst Century Century
National Committee for Quality Health Care 2003National Committee for Quality Health Care 2003
Quality of Care Incorporated in the “Drugs for the Elderly” Medicare Bill Passed by Congress
in 2003
Quality of Care Incorporated in the “Drugs for the Elderly” Medicare Bill Passed by Congress
in 2003Program DescriptionPay for performance IOM to develop a strategy for
aligning quality and paymentHospital to report on Hospitals that report will get performance 0.4% larger payments
Changing MD’s practice MD that participate will get
higher pay
Improving access for Develop demonstrationchronic illness (CHF) programsIT provision Grants for electronic
prescribing
Program DescriptionPay for performance IOM to develop a strategy for
aligning quality and paymentHospital to report on Hospitals that report will get performance 0.4% larger payments
Changing MD’s practice MD that participate will get
higher pay
Improving access for Develop demonstrationchronic illness (CHF) programsIT provision Grants for electronic
prescribing
Improvement in Performance Scores
90%86%
64%
85%
70%
93% 90%
76%
91%
80%
0%
20%
40%
60%
80%
100%
AMI CABG CHF Joint Repl Pneumonia
Before After
Pilot trial of Medicare Population: 270 Hospitals – 400,000 PatientsPilot trial of Medicare Population: 270 Hospitals – 400,000 Patients
Source: Centers for Medicare and Medicaid ServicesSource: Centers for Medicare and Medicaid Services
1990 1992 1994 1996 1998 2000 20021990
ACC/AHAAMI
R. Gunnar
1994AHCPR/NHLBI
UA E. Braunwald
1996 1999 Rev Upd ACC/AHA AMI T. Ryan
2004 2007 Rev Upd
ACC/AHA STEMI E. Antman
2000 2002 2007 Rev Upd Rev
ACC/AHA UA/NSTEMI E. Braunwald J. Anderson
2004 2007
Figure 1. Evolution of Guidelines for Management of Patients with AMI
The first guideline published by the ACC/AHA described the management of patients with acute myocardial infarction (AMI). The subsequent three documents were the Agency for Healthcare and Quality/National Heart, Lung and Blood Institute sponsored guideline on management of unstable angina (UA), the revised/updated ACC/AHA guideline on AMI, and the revised/updated ACC/AHA guideline on unstable angina/non-ST segment myocardial infarction (UA/NSTEMI). The present guideline is a revision and deals strictly with the management of patients presenting with ST segment elevation myocardial infarction (STEMI). The names of the chairs of the writing committees for each of the guidelines are shown at the bottom of each box. Rev, Revised; Upd, Update
Evolution of Guidelines for ACS
CRUSADE National Quality Improvement CRUSADE National Quality Improvement InitiativeInitiative
Academic collaboration between cardiology and Academic collaboration between cardiology and emergency medicine specialties started in 2001emergency medicine specialties started in 2001
Multiple industry sponsorsMultiple industry sponsors Millennium-Schering PloughMillennium-Schering Plough Bristol-Myers-SquibbBristol-Myers-Squibb Sanofi-AventisSanofi-Aventis Merck-ScheringMerck-Schering PDL PharmaPDL Pharma
Goal: Improve adherence to ACC/AHA ACS Goal: Improve adherence to ACC/AHA ACS guidelines guidelines UA and NSTEMI UA and NSTEMI STEMI added in 2004 STEMI added in 2004
Goals for CRUSADE: Improve Adherence to ACC/AHA Guidelines for
Patients with Unstable Angina/Non-STEMI
Goals for CRUSADE: Improve Adherence to ACC/AHA Guidelines for
Patients with Unstable Angina/Non-STEMI
Aspirin Clopidogrel
Beta Blocker Heparin (UFH or
LMWH) GP IIb-IIIa Inhibitor
All receiving cath/PCI
Aspirin Clopidogrel
Beta Blocker Heparin (UFH or
LMWH) GP IIb-IIIa Inhibitor
All receiving cath/PCI
Aspirin Clopidogrel Beta Blocker ACE Inhibitor Statin/Lipid Lowering Smoking Cessation Cardiac
Rehabilitation
Aspirin Clopidogrel Beta Blocker ACE Inhibitor Statin/Lipid Lowering Smoking Cessation Cardiac
Rehabilitation
Acute TherapiesAcute TherapiesAcute TherapiesAcute Therapies Discharge TherapiesDischarge TherapiesDischarge TherapiesDischarge Therapies
Circulation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines updateCirculation, JACC 2002 - ACC/AHA Guidelines update
Evaluating the Process of Care• An adherence score is applied to each patient. incorporating the components of process of care.• The score from each patient then combined for all patients at each hospital. Typical scores ranged from 50 to 95%.• All 400 hospital adherence scores then ranked in quartiles - best to worst.
Evaluating the Process of Care• An adherence score is applied to each patient. incorporating the components of process of care.• The score from each patient then combined for all patients at each hospital. Typical scores ranged from 50 to 95%.• All 400 hospital adherence scores then ranked in quartiles - best to worst.
Total sites = 568Total sites = 568(Active sites = 409)(Active sites = 409)
205,528 patients includedas of January 2007
AK(0)
WA(7)
OR(5)
CA(35)
ID(0)
NV(1)
MT(0)
WY(0)
CO(8)
NM(2)
ND(1)
SD(2)
NE (4)
KS(3)
OK(9)
TX(17)
MN(4)
IA(5)
MO(12)
AR(3)
LA(8)
WI(5) MI
(22)
MI
UT(1)
AZ(9)
HI (1)
IL(14)
IN(7)
KY(8)
TN(11)
MS(6)
AL(11)
GA(15)
FL(33)
SC(6)
NC(15)
VA(16)
OH(30)
WV(3)
PA(37)
NY(37)
MD (13)
ME(0)
VT (1)
NH (2)
NJ (10)
MA (11)
CT (8)
DE (3)
RI (1)
DC (1)
CRUSADE Site DistributionCRUSADE Site DistributionCRUSADE Site DistributionCRUSADE Site Distribution
AAcute cute
CCoronaryoronary
TTreatmentreatment and and IInterventionntervention
OOutcomes utcomes
NNetworketwork
National ACS Surveillance SystemNational ACS Surveillance System Assess characteristics, treatments, and Assess characteristics, treatments, and
outcomes of ACS patientsoutcomes of ACS patients Focuses on NSTEMI and STEMIFocuses on NSTEMI and STEMI
Optimize ACS management and outcomesOptimize ACS management and outcomes Implement evidence-based guideline Implement evidence-based guideline
recommendations in clinical practice recommendations in clinical practice
Improve quality and safety of ACS careImprove quality and safety of ACS care
Investigate novel QI methodsInvestigate novel QI methods
Follow Guidelines Adherence, Medication Dosing, Follow Guidelines Adherence, Medication Dosing, and Outcomes with the ACC-ACTIONand Outcomes with the ACC-ACTION Registry Registry
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
89%
69%
54%
45%
12%
0%
20%
40%
60%
80%
100%
Cath Cath < 48 hr PCI PCI < 48 hr CABG
ACTION/CRUSADE: April, 2006 – May, 2007
CRUSADE CRUSADE ACTION – NSTEMI Patients ACTION – NSTEMI PatientsInvasive Procedures in Cath-Eligible Population*Invasive Procedures in Cath-Eligible Population*
* Excludes ~25% of patients with cath contraindications
Early Cath (<48h) Use by Risk StatusEarly Cath (<48h) Use by Risk Status
20253035404550556065707580
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
2004
Q1
2004
Q2
2004
Q3
2004
Q4
Low RiskMod RiskHigh Risk
26.626.632.232.2
53.553.5
63.263.2
64.164.1
75.575.5
18%18%
21%21%
- Tricoci et al AHA 2005- Tricoci et al AHA 2005
Procedure Use as a Function of AgeProcedure Use as a Function of Age
- Alexander, JACC 2005- Alexander, JACC 2005
Rates of Cardiac Catheterization According to Predictive Risk of Severe CAD (L-Main or 3
Vessel) in ACS Patients
Rates of Cardiac Catheterization According to Predictive Risk of Severe CAD (L-Main or 3
Vessel) in ACS Patients
72.179.1 75.3
64.2
53.644.7
0
25
50
75
100
<10% 10-19% 20-29% 30-39% 40-49% ≥50%
Expected Risk of SCAD
Cad
iac
Cat
hete
riza
tion
(%)
n = 97,004n = 97,004
- Cohen, et al AHA 2005- Cohen, et al AHA 2005
Risk – Treatment ParadoxRisk – Treatment Paradox
0
10
20
30
40
50
60
% o
f P
atie
nts
1 2 3 4 5 6 7 8 9 10
Cath PCI CABG
Cath, p=0.0002; PCI, p=0.03; CABG, p=0.01Cath, p=0.0002; PCI, p=0.03; CABG, p=0.01
24.624.6
53.653.6
38.038.0
5.45.4
16.016.0
5.85.8
GRACE Risk Score (Deciles)GRACE Risk Score (Deciles)GRACE Risk Score (Deciles)GRACE Risk Score (Deciles)
92.6
63.4
82.3
59.5
76
64.8
47.5
85.2
38.9
78.8
58.5
70.2
50.1
27.8
0
10
20
30
40
50
60
70
80
90
100
Aspirin Clopidogrel B-Blocker ACE-I Statin SmokingCessation
CardiacRehab
Early Cath No Early Cath
Discharge Medication Use by Invasive Care –Discharge Medication Use by Invasive Care –UA/NSTEMI Patients from CRUSADEUA/NSTEMI Patients from CRUSADE
Per
cen
tag
e U
seP
erce
nta
ge
Use
Bhatt DL, JAMA 2004;292:2096-104.
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
Independent Predictors of Early CathIndependent Predictors of Early Cath
Adjusted Odds RatioAdjusted Odds Ratio
110.50.5 1.51.5 22
Cardiology CareCardiology Care
Age (per 10 yrs)Age (per 10 yrs)
Prior CHFPrior CHF
Renal InsufficiencyRenal Insufficiency
Signs of CHFSigns of CHF
Caucasian RaceCaucasian Race
Female SexFemale Sex
Bhatt et al, JAMA 2004Bhatt et al, JAMA 2004
A Reduction in the Use of Medical Strategy Alone in ACS Patients After
Introduction of DES
A Reduction in the Use of Medical Strategy Alone in ACS Patients After
Introduction of DES
30
35
40
45
50
55
60
Med
ical T
hera
py, %
FDA approves DES
p<0.01
- Gogo et al, ACC 2006- Gogo et al, ACC 2006
More PCI for 3-Vessel CAD After Introduction of DES
More PCI for 3-Vessel CAD After Introduction of DES
35
40
45
50
55
60
65
Perc
ent
CABG PCI
FDA approves DES
p<0.01 for trend in CABG rates
35
40
45
50
55
60
65
Perc
ent
CABG PCI
FDA approves DES
p<0.01 for trend in CABG rates
- Gogo et al, ACC 2006- Gogo et al, ACC 2006
Trends for DES Use for UA/NSTEMI – Trends for DES Use for UA/NSTEMI – CRUSADE to ACTION:CRUSADE to ACTION: July 2006 - March 2007July 2006 - March 2007
8981
72
0
10
20
30
40
50
60
70
80
90
100
Qtr 3 2006 Qtr 4 2006 Qtr 1 2007
% D
ES
am
on
g S
ten
t P
ts
The Use of Medical Therapy Alone in Patients The Use of Medical Therapy Alone in Patients With 3-Vessel CAD Has Been Constant Over TimeWith 3-Vessel CAD Has Been Constant Over Time
0
10
20
30
40
50
Perc
en
t
FDA approves DES
p=NS
- Gogo et al, ACC 2006- Gogo et al, ACC 2006
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
Use of Blood Transfusions in CRUSADEUse of Blood Transfusions in CRUSADE
0
5
10
15
20
25
< 55 yrs 55-64 yrs 65-74 yrs > 75 yrs Men Women no CRI CRI
% R
BC T
rans
fusio
n
Yang X, JACC 2005;46:1490-5.
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
Excessive Dosing of Anticoagulants by Age
Excessive Dosing of Anticoagulants by Age
12.5
28.7
8.512.5
3733.1
16.5
38.5
64.5
0
10
20
30
40
50
60
70
LMW Heparin UF Heparin GP IIb/IIIa
% E
xces
sive
Do
se
< 65 yrs 65-75 yrs >75 yrs
12.5
28.7
8.512.5
3733.1
16.5
38.5
64.5
0
10
20
30
40
50
60
70
LMW Heparin UF Heparin GP IIb/IIIa
% E
xces
sive
Do
se
< 65 yrs 65-75 yrs >75 yrs
-- Alexander JAMA 2005;294:3108-3116
42% of patients got excess
Dosing Combinations and Transfusions: Heparin + GP IIb-IIIa Inhibitors*
Dosing Combinations and Transfusions: Heparin + GP IIb-IIIa Inhibitors*
4.1
9
18.5
02468
101214161820
Both Right 1 Excessive BothExcessive
% R
BC
Tra
ns
fus
ion
s
* Among patients receiving both Heparin (UFH or LMWH) and GP IIb-IIIa Inhibitors* Among patients receiving both Heparin (UFH or LMWH) and GP IIb-IIIa Inhibitors
-- Alexander JAMA 2005;294:3108-3116
8
6.7
4.4
10.4
8.8
13.3
0
2
4
6
8
10
12
14
UF Heparin LMWH GP IIb-IIIa
Recommended Excess
CRUSADE RBC Transfusions by Excess DosingCRUSADE RBC Transfusions by Excess DosingR
BC
Tra
nsf
usi
on
(%
)R
BC
Tra
nsf
usi
on
(%
)
Alexander KA, JAMA 2005;294:3108-16. Alexander KA, JAMA 2005;294:3108-16.
35.8
14.1
25.9
33.9
14.2
21.6
0
10
20
30
40
UF Heparin LMWH GP IIb-IIIa
Q4 2005 Q4 2006
Impact of Overdosing Reporting in CRUSADEImpact of Overdosing Reporting in CRUSADEO
verd
osi
ng
(%
)O
verd
osi
ng
(%
)
CRUSADE Lessons LearnedCRUSADE Lessons Learned Complex patient populationComplex patient population
Variations in use of medicationsVariations in use of medications
Disparities in use of invasive proceduresDisparities in use of invasive procedures
Rapid changes in revascularization Rapid changes in revascularization proceduresprocedures
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing
Comprehensive guidelines adherence saves Comprehensive guidelines adherence saves liveslives
Academic output critical to successAcademic output critical to success
Link Between Overall ACC/AHA Guidelines Adherence and Mortality
Link Between Overall ACC/AHA Guidelines Adherence and Mortality
Peterson et al, ACC 2004Peterson et al, ACC 2004
5.95
5.16 4.97
4.16
5.074.63
4.17
6.33
0
1
2
3
4
5
6
7
<=25% 25 - 50% 50 - 75% >=75%
Hospital Composite Quality Quartiles
% I
n-H
osp
Mo
rtal
ity
Adjusted Unadjusted
5.95
5.16 4.97
4.16
5.074.63
4.17
6.33
0
1
2
3
4
5
6
7
<=25% 25 - 50% 50 - 75% >=75%
Hospital Composite Quality Quartiles
% I
n-H
osp
Mo
rtal
ity
Adjusted Unadjusted
Every 10% Every 10% in guidelines adherence in guidelines adherence 11% 11% in in mortalitymortality
Change in Mortality by Hospital Performance Improvement
Change in Mortality by Hospital Performance Improvement
-45-40-35-30-25-20-15-10
-505
% R
ela
tiv
e C
ha
ng
e in
Mo
rta
lity
Worsening N=78 No N=79 Modest N=79 Large N=79
-45-40-35-30-25-20-15-10
-505
% R
ela
tiv
e C
ha
ng
e in
Mo
rta
lity
Worsening N=78 No N=79 Modest N=79 Large N=79
Peterson et al, AHA 2004Peterson et al, AHA 2004
7.1%
4.9%
5.7%
4.3%
5.6%
4.9% 5.1%
4.1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
1st 2nd 3rd 4rth
Hospital Mortality According to How Consistently Hospitals Follow Trial Evidence
Quartiles of Hospital Composite of Medication Core Measures
Granger Am J Med. 2005;118:858-65 Granger Am J Med. 2005;118:858-65
Proportion of Patients Receiving 100% of All Guidelines-Recommended
Therapies*
Proportion of Patients Receiving 100% of All Guidelines-Recommended
Therapies*
16%
30% 30%
21%
36% 34%31%
46% 47%
33%
48% 50%
0%
25%
50%
75%
100%
Overall 100% CorrectMedication
Acute 100% CorrectMedication
Discharge 100% CorrectMedication
Q1Q4Q8Q11
*In patients without contraindications*In patients without contraindications
Mehta et al, AHA 2005Mehta et al, AHA 2005
CRUSADE Lessons Learned: ConclusionsCRUSADE Lessons Learned: Conclusions
Disparities in use of invasive proceduresDisparities in use of invasive procedures The highest risk patients frequently do not The highest risk patients frequently do not
undergo an invasive management in ACSundergo an invasive management in ACS
Rapid changes in revascularization proceduresRapid changes in revascularization procedures Substantial changes in DES and CABG use Substantial changes in DES and CABG use
during the last year highlights physician during the last year highlights physician uncertainty on safetyuncertainty on safety
Transfusions and bleeding are commonTransfusions and bleeding are common
Importance of proper medication dosingImportance of proper medication dosing Appropriate dosing of therapies need to be Appropriate dosing of therapies need to be
emphasized before and after interventionsemphasized before and after interventions