global registry of acute coronary events assessing todays practice patterns to enhance tomorrows...
TRANSCRIPT
Global Registry of Acute Global Registry of Acute Coronary EventsCoronary Events
Assessing Today’s Practice Patterns to Assessing Today’s Practice Patterns to Enhance Tomorrow’s CareEnhance Tomorrow’s Care
Supported by an unrestricted educational grant from Supported by an unrestricted educational grant from sanofi-aventis to the Center for Outcomes Research sanofi-aventis to the Center for Outcomes Research
University of Massachusetts Medical SchoolUniversity of Massachusetts Medical School
What is GRACE?What is GRACE?
Global Registry of Acute Coronary EventsGlobal Registry of Acute Coronary Events Largest multinational registry covering the full Largest multinational registry covering the full
spectrum of ACSspectrum of ACS Generalizable patient inclusion criteria Generalizable patient inclusion criteria In-hospital and 6-month follow-upIn-hospital and 6-month follow-up Representative of the catchment population: Representative of the catchment population:
(clusters of hospitals)(clusters of hospitals) Full spectrum of hospitals and facilitiesFull spectrum of hospitals and facilities Training, audit and quality controlTraining, audit and quality control
International Scientific International Scientific Advisory CommitteeAdvisory Committee
International Advisory CommitteeInternational Advisory Committee
‘Americas’ clustersChair: JM Gore
‘Americas’ clustersChair: JM Gore
‘European’ clustersChair: KAA Fox
‘European’ clustersChair: KAA Fox
8 advisors8 advisors 8 advisors8 advisors
40 subsite cardiologists
40 subsite cardiologists
40 subsite cardiologists
40 subsite cardiologists
Scientific Advisory CommitteeScientific Advisory Committee
ArgentinaArgentina Enrique GurfinkelEnrique GurfinkelAustralia/New ZealandAustralia/New ZealandDavid BriegerDavid BriegerAustriaAustriaGeorg GaulGeorg GaulBelgium Belgium Frans J Van de WerfFrans J Van de WerfBrazil Brazil Álvaro AvezumÁlvaro AvezumCanada Canada Shaun GoodmanShaun Goodman
Germany Germany Dietrich C GulbaDietrich C GulbaItalyItalyGiancarlo AgnelliGiancarlo AgnelliFranceFranceGilles MontalescotGilles MontalescotPh Gabriel StegPh Gabriel StegPolandPolandAndrzej BudajAndrzej BudajSpainSpain José López-SendónJosé López-Sendón
United KingdomUnited KingdomKeith AA FoxKeith AA FoxMarcus FlatherMarcus FlatherUnited StatesUnited StatesFrederick A AndersonFrederick A AndersonKim A EagleKim A EagleRobert J GoldbergRobert J GoldbergJoel M GoreJoel M GoreChristopher B GrangerChristopher B GrangerBrian M KennellyBrian M Kennelly
Co-ChairsCo-Chairs Keith AA Fox, UKKeith AA Fox, UKJoel M Gore, USAJoel M Gore, USA
Publications Publications Kim A Eagle, USAKim A Eagle, USACo-ChairsCo-Chairs Ph Gabriel Steg, FrancePh Gabriel Steg, France
Study Co-ordinationStudy Co-ordination Fred Anderson, University of Massachusetts Fred Anderson, University of Massachusetts
Objectives of GRACEObjectives of GRACE
Identify opportunities to improve the quality Identify opportunities to improve the quality of care for patients with ACSof care for patients with ACS
Describe diagnostic & treatment strategies, Describe diagnostic & treatment strategies, & hospital & post-discharge outcomes& hospital & post-discharge outcomes
Develop hypotheses for future clinical Develop hypotheses for future clinical researchresearch
Disseminate findings to a wider audienceDisseminate findings to a wider audience
Core GRACE Study Design Core GRACE Study Design
~100 hospitals in 14 countries~100 hospitals in 14 countries– Europe, North & South America, Australia, Europe, North & South America, Australia,
New Zealand New Zealand
Population-based clusters with community Population-based clusters with community
hospitals and referral centreshospitals and referral centres
First 10-20 consecutive cases per centre/month: First 10-20 consecutive cases per centre/month:
qualifying symptoms PLUS evidence of CADqualifying symptoms PLUS evidence of CAD
Random audit of all centres: 3 year cycleRandom audit of all centres: 3 year cycle
Cluster Strategy for Study Cluster Strategy for Study Sites: Population-Based DesignSites: Population-Based Design
~100 hospitals~10,000 ACS
patients/year
18 advisorycommitteemembers
18 advisorycommitteemembers
2
3
4
5
6
1
Multinational Site NetworkMultinational Site Network
ArgentinaArgentina 6 sites6 sites
AustraliaAustralia 7 sites7 sites
Austria Austria 6 site6 site
BelgiumBelgium 6 sites6 sites
BrazilBrazil 7 sites7 sites
CanadaCanada 6 sites6 sites
FranceFrance 6 sites6 sites
Germany Germany 5 sites5 sites
Italy Italy 5 sites5 sites
New Zealand New Zealand 2 sites2 sites
Poland Poland 6 sites6 sites
Spain Spain 4 sites4 sites
UK UK 5 sites5 sites
USA USA 18 sites18 sites
89 Active Core Study Sites: 89 Active Core Study Sites: 17 Clusters in 14 Countries17 Clusters in 14 Countries
Status of 17 Core ClustersStatus of 17 Core Clusters
70,359 cases enrolled70,359 cases enrolled
85% six-month follow-up 85% six-month follow-up
Q4-2007
The “Big Picture”The “Big Picture”Core GRACE & GRACECore GRACE & GRACE22
GRACE Core GRACE Core 70,359 patients70,359 patients89 hospitals89 hospitals14 countries14 countries
GRACE CoreGRACE Core
Substudy 1Substudy 2
Substudy 3
GRACEGRACE22 31,982 patients31,982 patients
158 hospitals158 hospitals23 countries23 countries
247 Core GRACE & GRACE247 Core GRACE & GRACE22 Study Sites in 30 Countries*Study Sites in 30 Countries*
*30 countries = 16 GRACE*30 countries = 16 GRACE2 2 + 7 core GRACE + 7 both+ 7 core GRACE + 7 both
Status: December 31, 2007Status: December 31, 200789 Core & 158 Expanded Sites89 Core & 158 Expanded Sites
30 countries30 countries
247 hospitals247 hospitals
102,341 cases102,341 cases
Q4-2007
Internet WebsiteInternet Websitewww.outcomes.org/gracewww.outcomes.org/grace
Hospital CharacteristicsHospital CharacteristicsQ4-2001 vs. Current QuarterQ4-2001 vs. Current Quarter
Q4-2001 Q4-2007Q4-2001 Q4-2007
Number of HospitalsNumber of Hospitals 109 109 89 89
Coronary care unitCoronary care unit 94% 94% 98% 98%
Emergency departmentEmergency department 86% 88%86% 88%
Cardiac catheterization laboratoryCardiac catheterization laboratory 65% 72% 65% 72%
Open heart surgeryOpen heart surgery 43% 45%43% 45%
Hospital beds (mean)Hospital beds (mean) 416 523 416 523
Coronary care unit beds (mean)Coronary care unit beds (mean) 10 11 10 11
ACS admissions (mean, per year)ACS admissions (mean, per year) 487 585 487 585Q4-2007
70,359 Cases Enrolled70,359 Cases Enrolledas of December 31, 2007as of December 31, 2007
2411
11543
19453
28699
38444
56081
62932
70359
48140
54848
27618
20303
36883
13245
6689
44453
233
50441
0
10000
20000
30000
40000
50000
60000
70000
80000
1999 2000 2001 2002 2003 2004 2005 2006 2007Year of Enrollment
Ca
se
s
Initial CRF 6-Month Follow-up
Q4-2007
34%
29%31%
7%
0%
10%
20%
30%
40%
STEMI UA NSTEMI Other
Pat
ien
ts (
%)
Q4-2007
Classification of CasesClassification of Cases
Hospital Discharge StatusHospital Discharge Status
STEMISTEMI NSTEMI UA NSTEMI UA
DeathDeath 7%7% 4%4% 3%3%
HomeHome 77%77% 78%78% 87%87%
Transfer Transfer ** 10%10% 12%12% 9%9%
OtherOther 6%6% 6%6% 2%2%
**Transfer to another acute care hospital.Transfer to another acute care hospital.
Q4-2007Q4-2007
*Missing diagnosis in 236 patients
UAN=4999(44%)
‘Rule-out’ MIN=957(9%)
Unspecified chest pain
N=745(7%)
Other cardiacN=381(3%)
Non-cardiacN=125(1%)
STEMIN=3419(30%)
Non-STEMIN=2893(25%)
Unstable anginaN=4397(38%)
Other cardiacN=508(4%)
Non-cardiacN=326(3%)
MIN=4100(36%)
Admission diagnoses versus final diagnoses (derived from discharge diagnosis, electrocardiographic changes and cardiac enzymes) in 11,543 patients with acute coronary syndromes. Figures expressed as percentage of total ACS.
Admission versus Final Admission versus Final DiagnosisDiagnosis
Fox KAA et al.Eur Heart J 2002;23:1177-89.Fox KAA et al.Eur Heart J 2002;23:1177-89.
Baseline CharacteristicsBaseline Characteristics
STEMI NSTEMI UASTEMI NSTEMI UA (n = 13,862) (11,316) (n = 13,862) (11,316) (12,509)(12,509)
Median age (years)Median age (years) 6565 6868 6666Male (%)Male (%) 7070 6666 6464Prior history (%)Prior history (%)• AnginaAngina 4343 5656 7878• Myocardial infarctionMyocardial infarction 2020 3232 4141• PCI/CABGPCI/CABG 8/58/5 15/1415/14 25/1925/19• SmokingSmoking 6262 5757 5555• Diabetes mellitus Diabetes mellitus 2121 2828 2626• Hypertension Hypertension 5252 6262 6666• Hyperlipidemia Hyperlipidemia 3838 4747 5454Participant in clin trial (%) 11Participant in clin trial (%) 1177 77
Hospital Treatment According Hospital Treatment According to Admission Diagnosisto Admission Diagnosis
MI MI UA UA ? MI? MI Chest painChest painn 16,304 15,266 3,474 3,266n 16,304 15,266 3,474 3,266
%% %% % % % %
ACE inhibitorsACE inhibitors 6969 56 56 5656 55 55
AspirinAspirin 9494 92 92 9292 92 92
-blockers-blockers 8383 81 81 8181 79 79
CaCa2+2+ blockers blockers 1515 34 34 3030 29 29
Gp IIb/IIIa: no PCIGp IIb/IIIa: no PCI 55 4 4 77 7 7
Gp IIb/IIIa with PCIGp IIb/IIIa with PCI 26 11 26 11 1515 18 18
LMWH LMWH 52 6452 64 4040 40 40
UFHUFH 5959 43 43 5151 51 51
Thrombolytic agentsThrombolytic agents 3535 2 2 33 3 3
Diagnostic ProceduresDiagnostic Procedures
78%73%
18%
69%60%
17%
58%
47%
25%
0%
20%
40%
60%
80%
100%
LVEF Echo Stress test
Pro
ced
ure
s (
%)
STEMI NSTEMI UA
Hospital Cardiac Interventions Hospital Cardiac Interventions According to Final DiagnosisAccording to Final Diagnosis
Intervention Intervention STEMI NSTEMI UASTEMI NSTEMI UAn 13,862 11,316 12,509n 13,862 11,316 12,509
%% %% % %
Cardiac catheterization Cardiac catheterization 6262 5757 4949
PCI PCI 4545 3131 2323
CABGCABG 44 77 66
Treatments at DischargeTreatments at Discharge
STEMI NSTEMI UASTEMI NSTEMI UAn 13,862 11,316 12,509n 13,862 11,316 12,509
%% %% % %
ACE inhibitors ACE inhibitors 6767 5656 5252
Aspirin Aspirin 9292 8989 8888
-blockers -blockers 7878 7676 7272
CaCa2+2+ blockers blockers 1010 2020 3131
Statins Statins 6363 5959 5757
Warfarin Warfarin 88 77 77
8
4
1.3
5
3
0.9
32
0.50
5
10
15
20
Death Major Bleed Stroke
Pat
ien
ts (
%)
STEMI (13,862)
NSTEMI (11,316)
UA (12,509)
Hospital Outcome by Hospital Outcome by Final DiagnosisFinal Diagnosis
Hospital OutcomesHospital Outcomes
0
4
8
12
Death Major bleed
Pat
ien
ts (
%)
Elderly patients (>=75)
Younger patients (65-<75)10.7
5.6
4.0
5.6
<0.0001
<0.0001
Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.
What proportion of eligible patients What proportion of eligible patients receive reperfusion therapy?receive reperfusion therapy?
Practice variation and missed opportunities for reperfusion in ST-segment-elevation myocardial infarction: findings from the Global Registry of Acute Coronary Events (GRACE)Kim A. Eagle, Shaun G. Goodman, Álvaro Avezum, Andrzej Budaj, Cynthia M. Sullivan, José López-Sendón, for the GRACE Investigators
Lancet 2002;359:373-77
Missed Opportunities for Missed Opportunities for ReperfusionReperfusion
ST ↑ or LBBB, <12 hrs from onset, no contraindications
ANC (%) US (%) AB (%)EUR (%) n 269 327 339 739
PCI alone 1.1 17.7 13.9 16.2 Lytic alone 66.9 30.6 53.1 49.4 Both 2.2 18.7 5.0 4.9 Neither 29.7 33.0 28.0 29.5
AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States
Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..
Independent Predictors of Independent Predictors of No ReperfusionNo Reperfusion
Variable OR (95% CI)
Prior CABG 2.28 (1.35 - 3.87)
History of diabetes 1.46 (1.11 -1.94)
History of congestive heart failure 2.92 (1.84 - 4.67)
Presentation without chest pain 2.23 (2.13 - 4.89)
*Age 75 years 2.37 (1.82 - 3.08)
*As compared to the <55 years age group
Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..
80 78
61
82
20 22
39
18
0
20
40
60
80
100
USA Europe ANC AB
Pa
tie
nts
(%
)
Cath lab No cath lab
ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil
Geographical Variation: Geographical Variation: Admission to Hospitals Admission to Hospitals with/without Access to Cath Labwith/without Access to Cath Lab
Global patterns of use of antithrombotic and antiplatelet therapies in patients with acute coronary syndromes: Insights from the Global Registry of Acute Coronary Events (GRACE)Andrzej Budaj, David Brieger, Ph Gabriel Steg, Shaun G. Goodman, Omar H. Dabbous, Keith A. A. Fox, Álvaro Avezum, Christopher P. Cannon, Tomasz Mazurek, Marcus D. Flather, and Frans Van De Werf, for the GRACE Investigators
Am Heart J 2003;146:999-1006.
3733
13
92
178
58
92
30
15
65
91
24
9
39
95
0
20
40
60
80
100
PCI GP IIb/IIIa LMWH ASA
Pat
ien
ts (
%)
United States
Australia/New Zealand/Canada
Europe
Argentina/Brazil
Geographic Practice VariationGeographic Practice Variation
Budaj A et al. Am Heart J 2003;146:999-1006.Budaj A et al. Am Heart J 2003;146:999-1006.
Antithrombotic Rx UsedAntithrombotic Rx Used
LMWH 46%
UFH 30%
UFH + llb/IIIa
4%
LMWH + llb/IIIa
2%
None 18%
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Incidence of Major BleedingIncidence of Major Bleeding
3.9
2.4
8.3
2.9
0
3
6
9
Major bleed
Pat
ien
ts (
%)
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Multivariate Adjusted Odds of Multivariate Adjusted Odds of Major HemorrhageMajor Hemorrhage
0 0.5 1 2 3Lower Higher
Major hemMajor hem 3.9%3.9%
2.4%2.4%
8.3%8.3%
2.9%2.9%
UFHUFH
LMWHLMWH
UFH +UFH +IIb/IIIaIIb/IIIa
LMWH +LMWH +IIb/IIIaIIb/IIIa
OR=0.55OR=0.55P<0.001P<0.001
OR=2.26OR=2.26
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Safety EventsSafety Events
0.1
0.7
1.2
0
0.6 0.7
0.3
0.6
0 0
2.9
1.5
0
1
2
3
ICH Stroke Plts
Pa
tie
nts
(%
)
UFHLMWHUFH + IIb/IIIaLMWH + IIb/IIIa
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Major Cardiac EventsMajor Cardiac Events
5
10.6
2.9
6.65
11.3
13.8
4.4
6.3
2.9
9.9
12.4
0
5
10
15
Death MI Death/MI
Pat
ien
ts (
%)
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE)
M. Moscucci, K.A.A. Fox, Christopher P. Cannon, W. Klein, José López-Sendón, G. Montalescot, K. White, R.J. Goldberg, for the GRACE Investigators
European Heart Journal 2003;24:1815-1823
Incidence of Major BleedingIncidence of Major Bleeding
3.9
2.3
4.7 4.8
0
1
2
3
4
5
6
Major Bleed
% o
f P
ati
en
ts
Overall UA
NSTEMI STEMI
Moscucci MMoscucci M et al.et al.Eur Heart J 2003;24:1815-23.Eur Heart J 2003;24:1815-23.
Predictors of Major Bleed Predictors of Major Bleed VariablesVariables OverallOverall UAUA STEMISTEMI NSTEMINSTEMI
Age (per 10 year Age (per 10 year ↑)↑) xx xx xx xxFemale genderFemale gender xx xx xxHistory of renal insufficiencyHistory of renal insufficiency xx xx xxHistory of bleedingHistory of bleeding xx xx xx xxKillip Class IVKillip Class IV xxMAP (per 20 mmHg MAP (per 20 mmHg ↓)↓) xx xxIV InotropicsIV Inotropics xx xx xx xx
Other vasodilatorsOther vasodilators xx xx
ThrombolyticsThrombolytics xx xxDiureticsDiuretics xx xx xx xxUnfractionated heparinUnfractionated heparin xx xxIIb/IIIa receptor blockersIIb/IIIa receptor blockers xx xx xxPA cathetersPA catheters xx xx xx xxPCIPCI xx xx xxThrombolytics and IIb/IIIa inhibThrombolytics and IIb/IIIa inhib xx xx xx
Moscucci MMoscucci M et al.et al.Eur Heart J 2003;24:1815-23.Eur Heart J 2003;24:1815-23.
5.13.0
5.3 7.0
18.616.1 15.3
22.8
0
10
20
30
40
50
Overall Unstable Angina NSTEMI STEMI
Pa
tie
nts
(%
)
No Major Bleed
Major Bleed
** ****
**P<0.001
In-Hospital Mortality RatesIn-Hospital Mortality Rates
**
Moscucci MMoscucci M et al.et al.Eur Heart J 2003;24:1815-23.Eur Heart J 2003;24:1815-23.
Outcome of “Low-risk” Outcome of “Low-risk” Patients with ACSPatients with ACS
Presentation with UA in the absence of dynamic Presentation with UA in the absence of dynamic ECG changes, no troponin elevation, no arrhythmia ECG changes, no troponin elevation, no arrhythmia nor hypotensionnor hypotension
Abnormal ECG in 38%, Abnormal ECG in 38%, 27% stress test, 37% echo, 52% angio27% stress test, 37% echo, 52% angio 6 month outcome:6 month outcome:
– 23% readmission23% readmission– 12% revascularized12% revascularized– 3% deaths3% deaths
““Low-risk” is not no riskLow-risk” is not no risk
Devlin et al.et al.Eur Heart J 2001;22(Abstr Suppl):525.Eur Heart J 2001;22(Abstr Suppl):525.
Total Population = 9,980Total Population = 9,980
Evidence Based MedicineEvidence Based Medicine
ST ST MI MI Non- ST Non- ST MI MI UAUA % of % of pts pts who who are are
TherapyTherapy (n=2,501)(n=2,501) (n=2,504)(n=2,504) (n=3,631)(n=3,631) eligibleeligible
ASAASA XX XX XX
B blockerB blocker XX XX
ACE-IACE-I XX XX
ReperfusionReperfusion XX
GP IIb/IIIa/LMWHGP IIb/IIIa/LMWH XX XXGranger CB et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):503A. 2001;37(2 Suppl A):503A.
GRACE: Use of EBM in GRACE: Use of EBM in “Eligible” Patients“Eligible” Patients
93%
81%
64%70%
58%
71%
57%
89%
0%
20%
40%
60%
80%
100%
ASA B-blocker ACE-I Reperf LMWH/IIb/IIIa
% I
deal
Use
In-hosp
Discharge
14% PTCA
56% lytics
14% IIb/IIIa
48% LMWH
n=5,373 n=4,480 n=3,254 n=1,963 n=4112
Granger CB et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):503A. 2001;37(2 Suppl A):503A.
Management of acute coronary syndromes. variations in practice and outcome: Findings from the Global Registry of Acute Coronary Events (GRACE)
K.A.A. Fox, S.G. Goodman, W. Klein, D. Brieger, P.G. Steg, O. Dabbous and Á. Avezum for the GRACE Investigators
Eur Heart J 2002;23:1177-1189
Geographic Practice Variation:Geographic Practice Variation:Discharge MedicationDischarge Medication
4753
94
4957
93
5450
94
53
26
93
0
20
40
60
80
100
ACE Statin AT/AC
Pat
ien
ts (
%)
United States
Australia/New Zealand/Canada
Europe
Argentina/Brazil
**P<0.01
AT/AC, antithrombin or anticoagulantFox KAA et al. Eur Heart J 2002;23:1177-89et al. Eur Heart J 2002;23:1177-89..
n=3420 of 8213 with CK, CK-MB
& troponin measurements
26
15
9
0
5
10
15
20
25
30
Troponin + in additionto CK ULN
Troponin + in additionto CK 2 x ULN
Troponin + in additionto CK-MB ULN
% In
cre
as
e in
Pa
tie
nts
w
ith
MI
Increase in Diagnosis of MI Increase in Diagnosis of MI Utilizing TroponinUtilizing Troponin
Goodman SG et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):358A 2001;37(2 Suppl A):358A..
In-Hospital MortalityIn-Hospital Mortality
5.8
32.1
0
2
4
6
8
CK 2 x ULNTroponin–
CK 2 x ULNTroponin +
CK > 2 x ULNTroponin–
CK > 2 x ULNTroponin +
Od
ds
Ra
tio
(1.6 - 5.7)
(0.6 - 7.4)
(3.3 - 10.1)
*
OR & 95% CI
*p<0.05
n=900n=900n=124n=124
*
Goodman SG et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):358A 2001;37(2 Suppl A):358A ..
n=1111n=1111
Impact of Aspirin on Presentation and Hospital Outcomes in Patients with Acute Coronary Syndromes (The Global Registry of Acute Coronary Events [GRACE])
Frederick A. Spencer, Jose J. Santopinto, Joel M. Gore, Robert J. Goldberg, Keith A.A. Fox, Mauro Moscucci, Kami White, and Enrique P. Gurfinkel
Am J Cardiol 2002;90:1056-1061
77.8
18.1
74.5
18.5
70.3
18.3
69.5
25.4
0
20
40
60
80
100
Hx of CAD (n=4974) No Hx of CAD (n=6414)
Prior long-ASA use according to geographic region and history
Per
cen
tag
e
Australia/New Zealand/CanadaEurope
South AmericaUSA
Impact of Prior ASA on ACS: Impact of Prior ASA on ACS: GRACEGRACE
Type of ACS and Hospital Type of ACS and Hospital Mortality in Patients with History Mortality in Patients with History of CAD Stratified By Prior ASAof CAD Stratified By Prior ASA
Impact of Impact of prior ASA on:prior ASA on:– STEMI 0.52 STEMI 0.52
(0.44,0.61)*(0.44,0.61)*– Death 0.69 Death 0.69
(0.5,0.95)**(0.5,0.95)**15
28
58
3
26 29
45
7
0
20
40
60
80
STEMI NSTEMI UA Death
Prior ASA No prior ASA
*Controlled for age, sex, medical hx, prior therapies, in hospital therapies
**Controlled for above plus MI type
Type of ACS and Hospital Mortality Type of ACS and Hospital Mortality in Patients without History of CAD in Patients without History of CAD Stratified By Prior ASAStratified By Prior ASA
Impact of prior Impact of prior ASA on:ASA on:– STEMI 0.35 STEMI 0.35
(0.30,0.40)*(0.30,0.40)*– Death 0.77 Death 0.77
(0.55,1.07)**(0.55,1.07)**
25
31
44
5
51
2723
6
0
20
40
60
STEMI NSTEMI UA Death
Prior ASA No prior ASA
*Controlled for age, sex, medical hx, prior therapies, in hospital therapies
** Controlled for above plus MI type
Association of Statin Therapy with Outcomes of Acute Coronary Syndromes: The GRACE Study
Frederick A. Spencer, Jeanna Allegrone, Robert J. Goldberg, Joel M. Gore, Keith A.A. Fox, Christopher B. Granger, Rajendra H. Mehta and David Brieger for the GRACE Investigators*
Ann Intern Med 2004;140:857-866
0
2000
4000
6000
8000
10000
12000
14000
16000
18000
Prior Statins No Prior Statins
Hospital Statins No Hospital Statins
Pa
tient
sPrior and Early Utilization of Statins Prior and Early Utilization of Statins in Patients with ACS: GRACEin Patients with ACS: GRACE
Ann. Intern Med. 2004;140:856-866.Ann. Intern Med. 2004;140:856-866.
Final Diagnosis of ACS Patients Final Diagnosis of ACS Patients According to Previous Treatment According to Previous Treatment with Statinswith Statins
0
20
40
60
80
100
Previous Statin Use No Previous Statin Use
Pa
tie
nts
, %
St elevation MI* non-ST elevation MI Unstable angina
*Multivariate analysis: Prior statin users less likely to present with STEMI -OR 0.79 (0.71,0.88)
Ann. Intern Med. 2004;140:856-866.Ann. Intern Med. 2004;140:856-866.
Hospital Outcomes of ACS Hospital Outcomes of ACS Patients Stratified by Statin UsePatients Stratified by Statin Use
Outcome Prior statins Prior & Hospital Hospital Statins Only Statin Only
Death 1.39 (0.91,2.14) 0.20 (0.16,0.25) 0.38 (0.30,0.48)
Recurrent MI 0.69 (0.43,1.11) 0.90 (0.75,1.07) 1.22 (1.08,1.37)
Stroke 1.08 (0.43,2.73) 0.68 (0.42, 1.12) 0.80 (0.57, 1.14)
Composite 1.02 (0.74,1.41) 0.66 (0.56,0.77) 0.87 (0.78,0.97)*Compared to patients never receiving statins
Ann. Intern Med. 2004;140:856-866.Ann. Intern Med. 2004;140:856-866.
Comparison of Outcomes of Patients With Acute Coronary Syndromes With and Without
Atrial Fibrillation
Rajendra H. Mehta, Omar H. Dabbous, Christopher B. Granger, Polina Kuznetsova, Eva M. Kline-Rogers, Frederick A. Anderson, Jr., Keith A.A. Fox, Joel M. Gore, Robert J. Goldberg and Kim A. Eagle for the GRACE Investigators
Ann J Cardiol 2003;92:1031-1036
Adjusted ORs for Hospital Adjusted ORs for Hospital Events in Patients with ACS and Events in Patients with ACS and New-Onset Atrial FibrillationNew-Onset Atrial Fibrillation
0 0.5 1 1.5 2 2.5 3 3.5 4
Odds Ratio
Major bleed
Stroke
Cardiac arrest
Pulmonary edema
Shock
Death
AF Better AF Worse
Am J Cardiol 2003;92(9):1031-6
Adjusted ORs for Hospital Events in Patients with ACS and Previous Atrial Fibrillation
0 0.5 1 1.5 2 2.5
Odds Ratio
Major bleed
Stroke
Cardiac arrest
Pulmonary edema
Shock
Death
AF Better AF Worse
Am J Cardiol 2003;92(9):1031-6
Determinants and Prognostic Impact of Heart Failure Complicating Acute Coronary Syndromes: Observations From the Global Registry of Acute Coronary Events (GRACE)
Philippe Gabriel Steg, Omar H. Dabbous, Laurent J. Feldman, Alain Cohen-Solal, Marie-Claude Aumont, José López-Sendón, Andrzej Budaj, Robert J. Goldberg, Werner Klein, Frederick A. Anderson, Jr, for the Global Registry of Acute Coronary Events (GRACE) Investigators
Circulation. 2004;109:494-499
Impact of Heart Failure on Impact of Heart Failure on Admission on Hospital MortalityAdmission on Hospital Mortality
1 10 20
>75 years
65-74 years
55-64 years
<55 years
3.1 (2.4,3.9)
3.3 (2.3,4.8)
5.0 (2.9,8.3)
10.1 (5.3,19.2)
Lower oddsratio for death Higher odds of death
*Relative to patients without HF
Circulation 2004;109:494-499.Circulation 2004;109:494-499.
Death Rates from Hospital Admission Death Rates from Hospital Admission to 6-Month Follow-Up for Patients to 6-Month Follow-Up for Patients According to Timing of Heart FailureAccording to Timing of Heart Failure
Circulation 2004;109:494-499. Circulation 2004;109:494-499.
Hospital Case-Fatality Rates Hospital Case-Fatality Rates According to Development of According to Development of Heart FailureHeart Failure
Group HF (+) HF (-)
All patients 12.0% 2.9%
STEMI 16.5% 4.1%
Non-STEMI 10.3% 3.0%
Unstable angina 6.7% 1.6%
Circulation 2004;109:494-499. Circulation 2004;109:494-499.
Stenting and Glycoprotein IIb/IIIa Inhibition in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Findings From the Global Registry of Acute Coronary Events (GRACE)
Gilles Montalescot, Frans Van de Werf, Dietrich C. Gulba, Àlvaro Avezum, David Brieger, Brian M. Kennelly, Tomasz Mazurek, Frederick Spencer, Kami White, and Joel M. Gore for the GRACE Investigators
Catheterization & Cardiovascular Interventions. 60:360-367 (2003)
Probability of Survival at Probability of Survival at 6 Months (all PCI)6 Months (all PCI)
Death rates:
+GP +stent 7.3% +GP –stent 12.8%
-GP +stent 6.7% -GP – stent 14.4%
Montalescot G et al.Catheter Cardiovasc Interv 2003;60:360-7.et al.Catheter Cardiovasc Interv 2003;60:360-7.
Probability of Survival at Probability of Survival at 6 Months (Primary PCI)6 Months (Primary PCI)
Death rates:
+GP +stent 7.7% +GP –stent 7.4%
-GP +stent 8.7% -GP –stent 20.1%
Montalescot G et al.Catheter Cardiovasc Interv 2003;60:360-7.et al.Catheter Cardiovasc Interv 2003;60:360-7.
Six-Month Outcomes in a Multinational Registry of Patients Hospitalized With an Acute Coronary Syndrome (The Global Registry of Acute Coronary Events [GRACE])
Robert J. Goldberg, Kristen Currie, Kami White, David Brieger, Phillippe Gabriel Steg, Shaun G. Goodman, Omar Dabbous, Keith A.A. Fox and Joel M. Gore for the GRACE Investigators
Am J Cardiol 2004;93:288-293
Six-Month Follow-Up*Six-Month Follow-Up*
STEMI NSTEMI UA
Death 5% (480/9414) 6% (496/7977) 4% (349/9357)
Stroke 1% (110/9173) 1% (103/7749) 1% (79/9176)
Rehospitalized 18% (1619/9147) 19% (1501/7721) 19% (1761/9150)
*Excluding events that occurred in hospital
Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.
16.2
9.3
5.0
14.7
8.07.1
15.7
8.3
6.1
0
5
10
15
20
Cardiac cath PCI CABG
Pat
ien
ts (
%)
STEMI (5,476)
NSTEMI (5,209)UA (6,149)
Discharge to 6 Month Outcomes: Discharge to 6 Month Outcomes: Cardiac InterventionsCardiac Interventions
Scheduled and unscheduled procedures
Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.
6 Month Follow-up6 Month Follow-up
5.8
12.2
19.7
6.47.8
18.5
4.1
23.1
27.6
5.7
18.1 19.0
0
5
10
15
20
25
30
Death MI Rehosp
Pat
ien
ts (
%)
UFHLMWH
UFH + IIb/IIIaLMWH + IIb/IIIa
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
12
3
17
13
3
20
8
1.5
20
0
10
20
30
Death Stroke Urgentreadmission forcardiac event
Pa
tie
nts
(%
)
STEMI (2075)
NSTEMI (1856)
UA (2883)
Total Outcomes: Total Outcomes: Admission to 6 MonthsAdmission to 6 Months
50
60
70
80
90
100
0 1 2 3 4 5 6
Months after hospital discharge
% S
urv
ivin
g
STEMI Non-STEMI UA
Survival Rate 6 Months Post Survival Rate 6 Months Post Discharge for STEMI, NSTEMI, Discharge for STEMI, NSTEMI, and UA Patientsand UA Patients
Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.
Factors Associated With An Factors Associated With An Increased Risk of Post-Discharge Increased Risk of Post-Discharge DeathDeath
Characteristic STEMI Non-STEMIAge (yrs) HR 95% CI HR 95% CI 65-74 3.48 2.00-6.06 2.17 1.27-3.72 >75 8.95 5.28-15.20 5.30 3.19-8.80
Medical history HF 2.21 1.61-3.04 2.20 1.71-2.84 MI 1.69 1.28-2.22 TIA/Stroke 1.37 1.03-1.84
Hospital complications Cardiogenic shock 1.94 1.20-3.15 HF 2.16 1.65-2.83 1.91 1.49-2.44 Stroke 2.51 1.32-4.78
Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.
Factors Associated with an Factors Associated with an Increased Risk of Post-Discharge Increased Risk of Post-Discharge Death in Patients with UADeath in Patients with UA
CharacteristicAge (yrs) HR 95% CI 55-64 3.34 1.81-6.19 65-74 5.29 2.88-9.72
Medical history HF 2.23 1.61-3.08 MI 1.44 1.09-1.91 PCI 0.52 0.35-0.77 Hospital complications Cardiogenic shock 4.01 1.73-9.28 HF 1.67 1.17-2.37
Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.
From guidelines to clinical practice: the impact of hospital and geographical characteristics on temporal trends in the management of acute coronary syndromes: The Global Registry of Acute Coronary Events (GRACE)
Keith A.A. Fox, Shaun G. Goodman, Frederick A. Anderson Jr., Christopher B.Granger, Mauro Moscucci, Marcus D. Flather , Frederick Spencer, Andrzej Budaj, Omar H. Dabbous, Joel M. Gore on behalf of the GRACE Investigators
European Heart Journal 2003;24:1414-1424
Temporal Trends in Temporal Trends in ACS Diagnostic CategoriesACS Diagnostic Categories
0%
10%
20%
30%
40%
50%
1999(n=5513)
2000(n=8787)
2001(n=8934)
2002(n=8944)
2003 (n=5924)
Year of Discharge
Pat
ien
ts (
%)
STEMI Non-STE MI UA
Temporal Trends STEMI: Temporal Trends STEMI: In-hospital TherapiesIn-hospital Therapies
Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24. *without PCI*without PCI
0
20
40
60
Jul-Dec1999
Jan-Jul2000
Jul-Dec2000
Jan-Jul2001
Jul-Dec2001
Year of Treatment
Pat
ien
ts (
%)
LMWH Ticl/Clop GPIIb/IIIa*
0
20
40
60
Jul-Dec1999
Jan-Jul2000
Jul-Dec2000
Jan-Jul2001
Jul-Dec2001
Year of Treatment
Pat
ien
ts (
%)
Lytics Primary PCI* No reperfusion
Temporal Trends STEMI: Temporal Trends STEMI: ReperfusionReperfusion
Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24. *within 12 h*within 12 h
0
20
40
60
80
Jul-Dec1999
Jan-Jul2000
Jul-Dec2000
Jan-Jul2001
Jul-Dec2001
Year of Treatment
Pat
ien
ts (
%)
LMWH Ticl/Clop GPIIb/IIIa
Temporal Trends NSTEMI:Temporal Trends NSTEMI:In-hospital TherapiesIn-hospital Therapies
Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24.
GRACE Palm Pilot SoftwareGRACE Palm Pilot SoftwareIn-hospital, 6-monthsIn-hospital, 6-months
Death, Death/MI Prediction ModelDeath, Death/MI Prediction Model
GRACE PDA SoftwareGRACE PDA Software
GRACE PDA SoftwareGRACE PDA Software
At Admission Risk ModelAt Admission Risk Model
At Discharge Risk Model At Discharge Risk Model
GRACE PublicationsGRACE Publications
Abstract Acceptance Rate Abstract Acceptance Rate (1999 to 2007)(1999 to 2007)
81%
52%
41%
0%
20%
40%
60%
80%
100%
ESC ACC AHA
Acc
epte
d (
%)
Number of abstracts accepted = 111
Manuscript StatusManuscript Status
16
8
7
12
66
0 20 40 60 80
Unprioritized
Top priorityindependent
Edit/write assistance
Submitted/beingrevised
Published/in press
GRACE Quarterly Reports to GRACE Quarterly Reports to InvestigatorsInvestigators
Quarterly ReportQuarterly ReportCurrent Quarter vs. OverallCurrent Quarter vs. Overall
Quarterly ReportQuarterly ReportTemporal TrendsTemporal Trends
Unique Features of GRACEUnique Features of GRACE
Multi-national perspectiveMulti-national perspective Full spectrum of coronary syndromesFull spectrum of coronary syndromes Increased data on demographics, Increased data on demographics,
presentation, management and outcomepresentation, management and outcome Regular audits of data qualityRegular audits of data quality Feedback to participating sitesFeedback to participating sites 6-month follow-up6-month follow-up