Background: Although obesity is a known risk factor for coronary artery disease, its impact on the presentation, treatment, and outcome of patients with acute coronary syndromes(ACS) has not been well studied. Methods...Background: Although obesity is a known risk factor for coronary artery disease, its impact on the presentation, treatment, and outcome of patients with acute coronary syndromes(ACS) has not been well studied. Methods: Using data from the CRUSADE Initiative, we compared inhospital treatments and clinical outcomes of 80 845 patients with high-risk non-ST-segment elevation(NSTE) ACS(positive cardiac markers and/or ischemic ST-segment changes) to determine whether there was an association with body mass index(BMI[kg/m2]). Patient weights were categorized according to World Health Organization classifications: Underweight(BMI< 18.5), Normal range(BMI 18.5-24.9), Overweight(BMI 25-29.9), Obese Class I(BMI 30-34.9), Obese Class Ⅱ(BMI 35-39.9), and Extremely Obese(BMI≥40). Results: Most(70.5%) of the CRUSADE patients were classified as overweight or obese; these patients were younger and more likely to present with comorbid conditions, including diabetes mellitus, hypertension, and hyperlipidemia. Medications given during the first 24 hours and invasive cardiac procedures recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were more commonly used in these patients. The incidence of death and death and reinfarction, adjusted for covariates, were generally lower in overweight and obese patients, compared with normal-weight patients, but higher in underweight and extremely obese patients. Conclusions: Most patients with NSTE ACS are overweight or obese. These patients receive more aggressive treatment, and, except for the extremely obese, have less adverse outcomes compared with underweight and normal-weight patients. Although obesity appears to be a risk factor for developing ACS at a younger age, it also appears to be associated with more aggressive ACS management and, ultimately, improved outcomes.展开更多
Objectives: We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting(CABG) and examine the drug’s impact on risks for postoperative transfusions among patients with non-ST-segment ...Objectives: We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting(CABG) and examine the drug’s impact on risks for postoperative transfusions among patients with non-ST-segment elevation acute coronary syndromes(NSTE ACS). Background: Adherence in community practice to American College of Cardiology/American Heart Association guidelines for clopidogrel use among NSTE ACS patients has not been previously characterized. Methods: We evaluated 2,858 NSTE ACS patients undergoing CABG at 264 hospitals participating in the CRUSADE(Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. We examined the patterns of acute clopidogrel therapy and its association with bleeding risks among those having “early”CABG ≤5 days and again among those having “late”surgery >5 days after catheterization. Results: Within 24 h of admission, 852 patients(30%) received clopidogrel. In contrast to national guidelines, 87%of clopidogrel-treated patients underwent CABG ≤5 days after treatment. Among those receiving CABG within ≤5 days of last treatment, the use of clopidogrel was associated with a significant increase in blood transfusions(65.0%vs. 56.9%, adjusted odds ratio[OR] 1.36, 95%confidence interval[CI] 1.10 to 1.68) as well as the need for transfusion of ≥4 U of blood(27.7%vs. 18.4%, OR 1.70, 95%CI 1.32 to 2.19). In contrast, acute clopidogrel therapy was not associated with higher bleeding risks if CABG was delayed >5 days(adjusted OR 1.18, 95%CI 0.54 to 2.58). Conclusions: Despite guideline recommendations, the overwhelming majority of NSTE ACS patients treated with acute clopidogrel needing CABG have their surgery within ≤5 days of treatment. A failure to delay surgery is associated with increased blood transfusion requirements that must be weighed against the potential clinical and economic impacts of such delays.展开更多
Background -Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevati...Background -Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes(NSTE ACS) and how different treatments affect outcomes. Methods and Results -Using data from 400 US hospitals participating in the CRUSADE(Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS(positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/ American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37 813(87.3%)white and 5504(12.7%) black patients. Black patients were younger;were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, β-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. Conclusions -Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.展开更多
文摘Background: Although obesity is a known risk factor for coronary artery disease, its impact on the presentation, treatment, and outcome of patients with acute coronary syndromes(ACS) has not been well studied. Methods: Using data from the CRUSADE Initiative, we compared inhospital treatments and clinical outcomes of 80 845 patients with high-risk non-ST-segment elevation(NSTE) ACS(positive cardiac markers and/or ischemic ST-segment changes) to determine whether there was an association with body mass index(BMI[kg/m2]). Patient weights were categorized according to World Health Organization classifications: Underweight(BMI< 18.5), Normal range(BMI 18.5-24.9), Overweight(BMI 25-29.9), Obese Class I(BMI 30-34.9), Obese Class Ⅱ(BMI 35-39.9), and Extremely Obese(BMI≥40). Results: Most(70.5%) of the CRUSADE patients were classified as overweight or obese; these patients were younger and more likely to present with comorbid conditions, including diabetes mellitus, hypertension, and hyperlipidemia. Medications given during the first 24 hours and invasive cardiac procedures recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS were more commonly used in these patients. The incidence of death and death and reinfarction, adjusted for covariates, were generally lower in overweight and obese patients, compared with normal-weight patients, but higher in underweight and extremely obese patients. Conclusions: Most patients with NSTE ACS are overweight or obese. These patients receive more aggressive treatment, and, except for the extremely obese, have less adverse outcomes compared with underweight and normal-weight patients. Although obesity appears to be a risk factor for developing ACS at a younger age, it also appears to be associated with more aggressive ACS management and, ultimately, improved outcomes.
文摘Objectives: We sought to characterize patterns of clopidogrel use before coronary artery bypass grafting(CABG) and examine the drug’s impact on risks for postoperative transfusions among patients with non-ST-segment elevation acute coronary syndromes(NSTE ACS). Background: Adherence in community practice to American College of Cardiology/American Heart Association guidelines for clopidogrel use among NSTE ACS patients has not been previously characterized. Methods: We evaluated 2,858 NSTE ACS patients undergoing CABG at 264 hospitals participating in the CRUSADE(Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines) Initiative. We examined the patterns of acute clopidogrel therapy and its association with bleeding risks among those having “early”CABG ≤5 days and again among those having “late”surgery >5 days after catheterization. Results: Within 24 h of admission, 852 patients(30%) received clopidogrel. In contrast to national guidelines, 87%of clopidogrel-treated patients underwent CABG ≤5 days after treatment. Among those receiving CABG within ≤5 days of last treatment, the use of clopidogrel was associated with a significant increase in blood transfusions(65.0%vs. 56.9%, adjusted odds ratio[OR] 1.36, 95%confidence interval[CI] 1.10 to 1.68) as well as the need for transfusion of ≥4 U of blood(27.7%vs. 18.4%, OR 1.70, 95%CI 1.32 to 2.19). In contrast, acute clopidogrel therapy was not associated with higher bleeding risks if CABG was delayed >5 days(adjusted OR 1.18, 95%CI 0.54 to 2.58). Conclusions: Despite guideline recommendations, the overwhelming majority of NSTE ACS patients treated with acute clopidogrel needing CABG have their surgery within ≤5 days of treatment. A failure to delay surgery is associated with increased blood transfusion requirements that must be weighed against the potential clinical and economic impacts of such delays.
文摘Background -Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes(NSTE ACS) and how different treatments affect outcomes. Methods and Results -Using data from 400 US hospitals participating in the CRUSADE(Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS(positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/ American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37 813(87.3%)white and 5504(12.7%) black patients. Black patients were younger;were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, β-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. Conclusions -Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.
