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Proven Heart Therapy Vastly Underutilized

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Duke Health News 919-660-1306

ATLANTA -- Duke University Medical Center researchers report that only one out of four patients with acute coronary syndromes receives drugs that have been proven to reduce death and heart attacks. The American Heart Association (AHA) and the American College of Cardiology (ACC) recommended that the drugs be used for high-risk patients with acute coronary syndromes.

The drugs in question, known as glycoprotein (GP) IIb/IIIa inhibitors, prevent blood clots from forming. If clots form, vessels in the heart may be blocked and heart attack or death may result. Patients who can benefit from the drugs will typically arrive at emergency rooms with chest pain (angina) and have non-ST-segment elevation myocardial infarction (NSTEMI) or unstable angina. It is estimated that about 715,000 Americans experience NSTEMI or unstable angina each year.

"Despite the fact that these drugs have been proven effective in preventing death and heart attacks, they are being markedly underutilized," said Duke cardiologist Eric Peterson, MD, who presented the results of the study today (March 18) at the 51st annual scientific sessions of the ACC. "This suggests that there is significant room for improvement in our treatment of these patients."

To conduct the study, Peterson consulted the National Registry of Myocardial Infarction (NRMI), a databank of patients who have suffered a heart attack. The fourth generation of this databank, NRMI 4, has been collecting data since July 2000. Of the 186,727 cases registered during that time, 60,770 were eligible for this new class of drugs.

Peterson's research also confirmed and expanded what is known about the treatment benefits of GP IIb/IIIa inhibitor agents. Specifically, the NRMI database represents "real world" patients who were older and sicker than those enrolled in the GP IIb/IIIa inhibitor trials.

"In this higher risk group of patients there was a 12 percent reduction in mortality seen in patients receiving therapy versus those who didn't after adjusting for risk factors," Peterson said. "The magnitude of this effect was similar to that seen in prior randomized studies, but given the current study's large size, it had the power to show this significant mortality benefit. This study's finding of under-use for these beneficial heart attack treatments should be a wake-up call to the profession to develop systems for assuring evidence-based care is provided to all."

In fact, one such nationwide awareness effort has just begun. Dubbed CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines), the effort plans to collect detailed data on how more than 60,000 high-risk heart patients are treated at 600 hospitals across the U.S.

Under CRUSADE, information will be collected during the next two years and feedback will be provided to individual hospitals on how their treatment patterns adhere to guidelines established by the ACC and AHA.

"This is the first initiative to retrospectively collect this kind of data on so many people with the goal of educating and thus influencing physician practice," said Duke cardiologist Matthew Roe, MD, who with Peterson is co-principal investigator of CRUSADE. "While the acute MI patients are at higher risk of dying within 30 days of their hospital stay, the patients we're looking at actually have a higher risk of dying six months and one year later. For this reason, this large group of patients not only needs to be treated early, but aggressively."

During a symposium at the ACC, Roe provided a sneak peek at the data collected on the first 2,026 cases. The ACC/AHA guidelines have shown that such evidence-based therapies as aspirin, beta-blockers and heparin -- when given early in this group of patients -- can reduce the risks of recurrent heart attacks and death. So far in CRUSADE, these common therapies were given in more than 80 percent of patients

As far as the GP IIb/IIIa inhibitors are concerned, 36 percent of the patients in CRUSADE received these agents within the first 24 hours of arriving at the hospital.

"While that appears to be an improvement over NRMI, these drugs still appear to be vastly underutilized," Roe said.

In order to ensure that proven therapies are given to patients in a timely fashion, the key is quickly identifying patients in the emergency room and evaluating their risk for future heart attacks. Based on the data received to date 89 percent of patients in CRUSADE were first seen in the emergency room.

"One of the truly unique aspects of CRUSADE is the close and equal participation of cardiologists with emergency room physicians in efforts to improve the quality of care," Roe explained. "If patients sit in an emergency room for a long time before admission, it is possible that they may not get the appropriate treatments until a cardiologist sees them. By then it may be too late to get the maximum benefit from proven therapies. CRUSADE provides a platform for cardiologists and emergency medicine physicians to work together to reduce treatment delays and improve the use of beneficial therapies."

The data collected so far comes from approximately 80 participating hospitals. By summer, it is anticipated that 600 hospitals will be providing detailed data. The hospitals cover the spectrum of small community hospitals to major academic medical centers, and all geographic regions are represented.

The NRMI databank is funded by Genentech, Inc., South San Francisco, Calif.

CRUSADE is funded by Millennium Pharmaceuticals, Inc., Cambridge, MA, and Key-ACS, a division of Schering-Plough Corp., Kenilworth, NJ. Peterson and Roe are consultants for these companies.

The executive co-chairmen of CRUSADE are Brian Gibler, MD, chairman of the department of emergency medicine at the University of Cincinnati School of Medicine, and E. Magnus Ohman, MD, chief of the division of cardiology at the University of North Carolina at Chapel Hill.

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