Transcript These Power Point slides are for the use of all GRACE

Global Registry of Acute
Coronary Events
Assessing Today’s Practice Patterns to
Enhance Tomorrow’s Care
Supported by an unrestricted educational grant from
sanofi-aventis to the Center for Outcomes Research
University of Massachusetts Medical School
What is GRACE?
Global Registry of Acute Coronary Events
 Largest multinational registry covering the full
spectrum of ACS
 Generalizable patient inclusion criteria
 In-hospital and 6-month follow-up
 Representative of the catchment population:
(clusters of hospitals)
 Full spectrum of hospitals and facilities
 Training, audit and quality control
International Scientific
Advisory Committee
International Advisory Committee
‘Americas’ clusters
Chair: JM Gore
‘European’ clusters
Chair: KAA Fox
8 advisors
8 advisors
40 subsite
cardiologists
40 subsite
cardiologists
Scientific Advisory Committee
Co-Chairs Keith AA Fox, UK
Joel M Gore, USA
Publications
Co-Chairs
Kim A Eagle, USA
Ph Gabriel Steg, France
Study Co-ordination Fred Anderson, University of Massachusetts
Argentina
Enrique Gurfinkel
Australia/New Zealand
David Brieger
Austria
Georg Gaul
Belgium
Frans J Van de Werf
Brazil
Álvaro Avezum
Canada
Shaun Goodman
Germany
Dietrich C Gulba
Italy
Giancarlo Agnelli
France
Gilles Montalescot
Ph Gabriel Steg
Poland
Andrzej Budaj
Spain
José López-Sendón
United Kingdom
Keith AA Fox
Marcus Flather
United States
Frederick A Anderson
Kim A Eagle
Robert J Goldberg
Joel M Gore
Christopher B Granger
Brian M Kennelly
Objectives of GRACE
 Identify opportunities to improve the quality
of care for patients with ACS
 Describe diagnostic & treatment strategies,
& hospital & post-discharge outcomes
 Develop hypotheses for future clinical
research
 Disseminate findings to a wider audience
Core GRACE Study Design
 ~100 hospitals in 14 countries
– Europe, North & South America, Australia,
New Zealand
 Population-based clusters with community
hospitals and referral centres
 First 10-20 consecutive cases per centre/month:
qualifying symptoms PLUS evidence of CAD
 Random audit of all centres: 3 year cycle
Cluster Strategy for Study
Sites: Population-Based Design
2
1
3
~100 hospitals
~10,000 ACS
patients/year
18 advisory
committee
members
4
6
5
Multinational Site Network
Argentina 6 sites
Germany
5 sites
Australia
7 sites
Italy
5 sites
Austria
6 site
New Zealand 2 sites
Belgium
6 sites
Poland
6 sites
Brazil
7 sites
Spain
4 sites
Canada
6 sites
UK
5 sites
France
6 sites
USA
18 sites
89 Active Core Study Sites:
17 Clusters in 14 Countries
Status of 17 Core Clusters
 70,359 cases enrolled
 85% six-month follow-up
Q4-2007
The “Big Picture”
Core GRACE & GRACE2
GRACE Core
Substudy 1
Substudy 3
Substudy 2
GRACE Core
70,359 patients
89 hospitals
14 countries
GRACE2
31,982 patients
158 hospitals
23 countries
247 Core GRACE & GRACE2
Study Sites in 30 Countries*
*30 countries = 16 GRACE2 + 7 core GRACE + 7 both
Status: December 31, 2007
89 Core & 158 Expanded Sites
 30 countries
 247 hospitals
 102,341 cases
Q4-2007
Internet Website
www.outcomes.org/grace
Hospital Characteristics
Q4-2001 vs. Current Quarter
Q4-2001
Q4-2007
Number of Hospitals
109
89
Coronary care unit
94%
98%
Emergency department
86%
88%
Cardiac catheterization laboratory
65%
72%
Open heart surgery
43%
45%
Hospital beds (mean)
416
523
10
11
487
585
Coronary care unit beds (mean)
ACS admissions (mean, per year)
Q4-2007
70,359 Cases Enrolled
as of December 31, 2007
80000
Initial CRF
6-Month Follow-up
70359
70000
62932
56081
Cases
60000
48140
50000
38444
40000
28699
30000
19453
13245
11543
6689
20000
10000
50441
54848
44453
36883
27618
20303
2411
233
0
1999
Q4-2007
2000
2001
2002
2003
2004
Year of Enrollment
2005
2006
2007
Classification of Cases
40%
34%
29%
Patients (%)
30%
31%
20%
10%
7%
0%
STEMI
Q4-2007
UA
NSTEMI
Other
Hospital Discharge Status
STEMI
NSTEMI
UA
Death
7%
4%
3%
Home
77%
78%
87%
Transfer *
10%
12%
9%
6%
6%
2%
Other
*Transfer to another acute care hospital.
Q4-2007
Admission versus Final
Diagnosis
MI
N=4100
(36%)
UA
N=4999
(44%)
‘Rule-out’ MI
N=957
(9%)
Unspecified
chest pain
N=745
(7%)
Other cardiac
N=381
(3%)
Non-cardiac
N=125
(1%)
*Missing diagnosis in 236 patients
STEMI
N=3419
(30%)
Non-STEMI
N=2893
(25%)
Unstable
angina
N=4397
(38%)
Other cardiac
N=508
(4%)
Non-cardiac
N=326
(3%)
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.
Fox KAA et al.Eur Heart J 2002;23:1177-89.
Baseline Characteristics
STEMI
(n = 13,862)
Median age (years)
Male (%)
Prior history (%)
• Angina
• Myocardial infarction
• PCI/CABG
• Smoking
• Diabetes mellitus
• Hypertension
• Hyperlipidemia
Participant in clin trial (%)
65
70
43
20
8/5
62
21
52
38
117
NSTEMI
(11,316)
UA
(12,509)
68
66
66
64
56
32
15/14
57
28
62
47
7
78
41
25/19
55
26
66
54
Hospital Treatment According
to Admission Diagnosis
n
ACE inhibitors
Aspirin
-blockers
Ca2+ blockers
Gp IIb/IIIa: no PCI
Gp IIb/IIIa with PCI
LMWH
UFH
Thrombolytic agents
MI
16,304
UA
15,266
? MI
3,474
Chest pain
3,266
%
%
%
%
69
94
83
15
5
26
52
59
35
56
92
81
34
4
11
64
43
2
56
92
81
30
7
15
40
51
3
55
92
79
29
7
18
40
51
3
Diagnostic Procedures
100%
STEMI
Procedures (%)
80%
60%
78%
NSTEMI
UA
73%
69%
58%
60%
47%
40%
25%
18%17%
20%
0%
LVEF
Echo
Stress test
Hospital Cardiac Interventions
According to Final Diagnosis
Intervention
n
NSTEMI
11,316
UA
12,509
Cardiac catheterization
%
62
%
57
%
49
PCI
45
31
23
4
7
6
CABG
STEMI
13,862
Treatments at Discharge
NSTEMI
11,316
UA
12,509
ACE inhibitors
%
67
%
56
%
52
Aspirin
92
89
88
-blockers
78
76
72
Ca2+ blockers
10
20
31
Statins
63
59
57
8
7
7
n
Warfarin
STEMI
13,862
Hospital Outcome by
Final Diagnosis
20
STEMI (13,862)
Patients (%)
NSTEMI (11,316)
15
10
UA (12,509)
8
5
5
3
4
3
2
1.3 0.9
0.5
0
Death
Major Bleed
Stroke
Hospital Outcomes
Patients (%)
12
<0.0001
Elderly patients (>=75)
10.7
Younger patients (65-<75)
<0.0001
8
5.6
5.6
4.0
4
0
Death
Major bleed
Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.
What proportion of eligible patients
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
Reperfusion
ST ↑ or LBBB, <12 hrs from onset, no contraindications
n
PCI alone
Lytic alone
Both
Neither
ANC (%)
269
US (%)
327
AB (%)
339
1.1
66.9
2.2
29.7
17.7
30.6
18.7
33.0
13.9
53.1
5.0
28.0
EUR (%)
739
16.2
49.4
4.9
29.5
AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States
Eagle KA et al. Lancet 2002;359:373-7.
Independent Predictors of
No Reperfusion
Variable
OR (95% CI)
Prior CABG
History of diabetes
History of congestive heart failure
Presentation without chest pain
*Age 75 years
2.28 (1.35 - 3.87)
1.46 (1.11 -1.94)
2.92 (1.84 - 4.67)
2.23 (2.13 - 4.89)
2.37 (1.82 - 3.08)
*As compared to the <55 years age group
Eagle KA et al. Lancet 2002;359:373-7.
Geographical Variation:
Admission to Hospitals
with/without Access to Cath Lab
100
Cath lab
80
82
78
80
Patients (%)
No cath lab
61
60
39
40
20
22
18
20
0
USA
Europe
ANC
ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil
AB
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.
Geographic Practice Variation
100
92 92 91 95
United States
Australia/New Zealand/Canada
Patients (%)
80
Europe
65
Argentina/Brazil
58
60
40
37
39
33
30
24
20
17
15
8
9
13
0
PCI
GP IIb/IIIa
LMWH
ASA
Budaj A et al. Am Heart J 2003;146:999-1006.
Antithrombotic Rx Used
LMWH +
llb/IIIa
2%
None
18%
UFH
30%
UFH +
llb/IIIa
4%
LMWH
46%
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Incidence of Major Bleeding
Patients (%)
9
6
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
8.3
3.9
3
2.4
2.9
0
Major bleed
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Multivariate Adjusted Odds of
Major Hemorrhage
Major hem
UFH
LMWH
3.9%
OR=0.55
P<0.001
2.4%
UFH +
IIb/IIIa
OR=2.26
8.3%
LMWH +
IIb/IIIa
2.9%
0
0.5
Lower
1
2
3
Higher
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Safety Events
Patients (%)
3
2
2.9
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
1.5
1.2
1
0.7 0.6 0.6
0.7
0.3
0
0.1 0
ICH
0
0
Stroke
 Plts
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Major Cardiac Events
Patients (%)
15
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
10
13.8
12.4
11.3
9.9
10.6
6.3 6.6
5
5
5
4.4
2.9 2.9
0
Death
MI
Death/MI
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
% of Patients
Incidence of Major Bleeding
6
Overall
UA
5
NSTEMI
STEMI
4
4.7
4.8
3.9
3
2.3
2
1
0
Major Bleed
Moscucci M et al.Eur Heart J 2003;24:1815-23.
Predictors of Major Bleed
Variables
Overall
Age (per 10 year ↑)
Female gender
History of renal insufficiency
History of bleeding
Killip Class IV
MAP (per 20 mmHg ↓)
IV Inotropics
x
x
x
x
Other vasodilators
Thrombolytics
Diuretics
Unfractionated heparin
IIb/IIIa receptor blockers
PA catheters
PCI
Thrombolytics and IIb/IIIa inhib
x
x
x
x
x
x
x
x
UA
x
x
x
x
x
x
x
x
STEMI
NSTEMI
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
Moscucci M et al.Eur Heart J 2003;24:1815-23.
x
x
x
x
x
x
x
In-Hospital Mortality Rates
50
No Major Bleed
Major Bleed
Patients (%)
40
**
30
18.6
20
10
**
5.1
22.8
16.1
3.0
**
**
15.3
5.3
7.0
0
Overall
Unstable Angina
NSTEMI
**P<0.001
Moscucci M et al.Eur Heart J 2003;24:1815-23.
STEMI
Outcome of “Low-risk”
Patients with ACS
 Presentation with UA in the absence of dynamic
ECG changes, no troponin elevation, no arrhythmia
nor hypotension
 Abnormal ECG in 38%,
 27% stress test, 37% echo, 52% angio
 6 month outcome:
– 23% readmission
– 12% revascularized
– 3% deaths
 “Low-risk” is not no risk
Devlin et al.Eur Heart J 2001;22(Abstr Suppl):525.
Evidence Based Medicine
Total Population = 9,980
ST  MI Non- ST  MI UA
Therapy
% of pts
who are
(n=2,501) (n=2,504) (n=3,631) eligible
ASA
X
X
B blocker
X
X
ACE-I
X
X
Reperfusion
X
GP IIb/IIIa/LMWH
X
X
X
Granger CB et al. J Am Coll Cardiol 2001;37(2 Suppl A):503A.
GRACE: Use of EBM in
“Eligible” Patients
100%
93%
89%
In-hosp
Discharge
81%
80%
71%
70%
% Ideal Use
64%
57%
60%
14%
PTCA
40%
56%
lytics
20%
58%
14%
IIb/IIIa
48%
LMWH
0%
ASA
n=5,373
B-blocker
n=4,480
ACE-I
Reperf
n=3,254
n=1,963
LMWH/IIb/IIIa
n=4112
Granger CB et al. J Am Coll Cardiol 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:
Discharge Medication
United States
100
94
93 94 93
Australia/New Zealand/Canada
Europe
Patients (%)
80
Argentina/Brazil
60
47
49
54 53
53
57
50
40
26
20
0
**P<0.01
ACE
AT/AC, antithrombin or anticoagulant
Statin
AT/AC
Fox KAA et al. Eur Heart J 2002;23:1177-89.
Increase in Diagnosis of MI
Utilizing Troponin
30
n=3420 of 8213
with CK, CK-MB
& troponin
measurements
% Increase in Patients
with MI
26
25
20
15
15
9
10
5
0
Troponin + in addition
to CK  ULN
Troponin + in addition
to CK  2 x ULN
Troponin + in addition
to CK-MB  ULN
Goodman SG et al. J Am Coll Cardiol 2001;37(2 Suppl A):358A.
In-Hospital Mortality
8
OR & 95% CI
n=1111
5.8 *
(3.3 - 10.1)
Odds Ratio
6
n=900
3*
4
(1.6 - 5.7)
n=124
2.1
(0.6 - 7.4)
2
0
CK  2 x ULN
Troponin–
*p<0.05
CK  2 x ULN
Troponin +
CK > 2 x ULN
Troponin–
CK > 2 x ULN
Troponin +
Goodman SG et al. J Am Coll Cardiol 2001;37(2 Suppl A):358A
.
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
Impact of Prior ASA on ACS:
GRACE
100
Percentage
80
77.8 74.5
70.3 69.5
Australia/New Zealand/Canada
Europe
South America
USA
60
40
25.4
20
18.1 18.5 18.3
0
Hx of CAD (n=4974)
No Hx of CAD (n=6414)
Prior long-ASA use according to geographic region
and history
Type of ACS and Hospital
Mortality in Patients with History
of CAD Stratified By Prior ASA
80
Prior ASA
 Impact of
prior ASA on:
No prior ASA
58
60
– STEMI 0.52
(0.44,0.61)*
– Death 0.69
(0.5,0.95)**
45
40
26
20
28 29
15
3
7
0
STEMI
NSTEMI
UA
Death
*Controlled for age, sex, medical hx, prior therapies, in hospital therapies
**Controlled for above plus MI type
Type of ACS and Hospital Mortality
in Patients without History of CAD
Stratified By Prior ASA
60
51
Prior ASA
No prior ASA
 Impact of prior
ASA on:
44
– STEMI 0.35
(0.30,0.40)*
– Death 0.77
(0.55,1.07)**
40
31
27
25
23
20
5
6
0
STEMI
NSTEMI
UA
Death
*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
Prior and Early Utilization of Statins
in Patients with ACS: GRACE
18000
16000
Hospital Statins
No Hospital Statins
14000
12000
10000
8000
6000
4000
2000
0
Prior Statins
No Prior Statins
Ann. Intern Med. 2004;140:856-866.
Final Diagnosis of ACS Patients
According to Previous Treatment
with Statins
St elevation MI*
non-ST elevation MI
Unstable angina
100
Patients, %
80
60
40
20
0
Previous Statin Use
No Previous Statin Use
*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.
Hospital Outcomes of ACS
Patients Stratified by Statin Use
Outcome
Prior statins
Only
Prior & Hospital
Statin
Hospital Statins
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.
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
Events in Patients with ACS and
New-Onset Atrial Fibrillation
AF Better
AF Worse

Major bleed

Stroke

Cardiac arrest

Pulmonary edema

Shock

Death
0
0.5
1
1.5
2
2.5
Odds Ratio
Am J Cardiol 2003;92(9):1031-6
3
3.5
4
Adjusted ORs for Hospital Events
in Patients with ACS and Previous
Atrial Fibrillation
AF Better
AF Worse

Major bleed

Stroke

Cardiac arrest

Pulmonary edema

Shock

Death
0
0.5
1
1.5
Odds Ratio
Am J Cardiol 2003;92(9):1031-6
2
2.5
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
Admission on Hospital Mortality
>75 years
3.1 (2.4,3.9)
65-74 years
3.3 (2.3,4.8)
5.0 (2.9,8.3)
55-64 years
10.1 (5.3,19.2)
<55 years
1
Lower odds
ratio for death
10
Higher odds of death
*Relative to patients without HF
Circulation 2004;109:494-499.
20
Death Rates from Hospital Admission
to 6-Month Follow-Up for Patients
According to Timing of Heart Failure
Circulation 2004;109:494-499.
Hospital Case-Fatality Rates
According to Development of
Heart Failure
Group
HF (+)
HF (-)
All patients
12.0%
2.9%
STEMI
16.5%
4.1%
Non-STEMI
10.3%
3.0%
6.7%
1.6%
Unstable angina
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
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.
Probability of Survival at
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.
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*
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
Goldberg RJ et al.Am J Cardiol 2004;93:288-93.
Discharge to 6 Month Outcomes:
Cardiac Interventions
Scheduled and unscheduled procedures
20
Patients (%)
16.2
15
14.7
STEMI (5,476)
NSTEMI (5,209)
UA (6,149)
15.7
9.3
10
8.0 8.3
7.1
5.0
6.1
5
0
Cardiac cath
PCI
CABG
Goldberg RJ et al.Am J Cardiol 2004;93:288-93.
6 Month Follow-up
30
Patients (%)
25
20
15
10
5
27.6
UFH
LMWH
UFH + IIb/IIIa
LMWH + IIb/IIIa
23.1
18.1
19.7
18.5
19.0
12.2
5.8 6.4
7.8
4.1
5.7
0
Death
MI
Rehosp
Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.
Total Outcomes:
Admission to 6 Months
Patients (%)
30
STEMI (2075)
NSTEMI (1856)
UA (2883)
20
20
20
17
12
13
8
10
3
3
1.5
0
Death
Stroke
Urgent
readmission for
cardiac event
Survival Rate 6 Months Post
Discharge for STEMI, NSTEMI,
and UA Patients
100
% Surviving
90
80
STEMI
Non-STEMI
UA
70
60
50
0
1
2
3
4
Months after hospital discharge
Goldberg RJ et al.Am J Cardiol 2004;93:288-93.
5
6
Factors Associated With An
Increased Risk of Post-Discharge
Death
Characteristic
Age (yrs)
65-74
>75
STEMI
HR 95% CI
3.48 2.00-6.06
8.95 5.28-15.20
Non-STEMI
HR 95% CI
2.17 1.27-3.72
5.30 3.19-8.80
Medical history
HF
MI
TIA/Stroke
2.21 1.61-3.04
1.69 1.28-2.22
2.20 1.71-2.84
Hospital complications
Cardiogenic shock
HF
Stroke
1.37 1.03-1.84
1.94 1.20-3.15
2.16 1.65-2.83
2.51 1.32-4.78
1.91 1.49-2.44
Goldberg RJ et al.Am J Cardiol 2004;93:288-93.
Factors Associated with an
Increased Risk of Post-Discharge
Death in Patients with UA
Characteristic
Age (yrs)
55-64
65-74
HR
3.34
5.29
95% CI
1.81-6.19
2.88-9.72
Medical history
HF
MI
PCI
2.23
1.44
0.52
1.61-3.08
1.09-1.91
0.35-0.77
Hospital complications
Cardiogenic shock
HF
4.01
1.67
1.73-9.28
1.17-2.37
Goldberg RJ 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
ACS Diagnostic Categories
STEMI
Non-STE MI
UA
50%
Patients (%)
40%
30%
20%
10%
0%
1999
(n=5513)
2000
(n=8787)
2001
(n=8934)
2002
(n=8944)
Year of Discharge
2003
(n=5924)
Temporal Trends STEMI:
In-hospital Therapies
Patients (%)
60
LMWH
Ticl/Clop
GPIIb/IIIa*
40
20
0
Jul-Dec
1999
Jan-Jul
2000
Jul-Dec
2000
Jan-Jul
2001
Year of Treatment
*without PCI
Fox KAA et al. Eur Heart J 2003;24:1414-24.
Jul-Dec
2001
Temporal Trends STEMI:
Reperfusion
Patients (%)
60
Lytics
Primary PCI*
No reperfusion
40
20
0
Jul-Dec
1999
Jan-Jul
2000
Jul-Dec
2000
Jan-Jul
2001
Year of Treatment
*within 12 h
Fox KAA et al. Eur Heart J 2003;24:1414-24.
Jul-Dec
2001
Temporal Trends NSTEMI:
In-hospital Therapies
Patients (%)
80
LMWH
Ticl/Clop
GPIIb/IIIa
60
40
20
0
Jul-Dec
1999
Jan-Jul
2000
Jul-Dec
2000
Jan-Jul
2001
Year of Treatment
Fox KAA et al. Eur Heart J 2003;24:1414-24.
Jul-Dec
2001
GRACE Palm Pilot Software
In-hospital, 6-months
Death, Death/MI Prediction Model
GRACE PDA Software
GRACE PDA Software
At Admission Risk Model
At Discharge Risk Model
GRACE Publications
Abstract Acceptance Rate
(1999 to 2007)
Number of abstracts accepted = 111
100%
81%
Accepted (%)
80%
60%
52%
41%
40%
20%
0%
ESC
ACC
AHA
Manuscript Status
66
Published/in press
Submitted/being
revised
12
7
Edit/write assistance
Top priority
independent
8
16
Unprioritized
0
20
40
60
80
GRACE Quarterly Reports to
Investigators
Quarterly Report
Current Quarter vs. Overall
Quarterly Report
Temporal Trends
Unique Features of GRACE
 Multi-national perspective
 Full spectrum of coronary syndromes
 Increased data on demographics,
presentation, management and outcome
 Regular audits of data quality
 Feedback to participating sites
 6-month follow-up