Association of statin therapy with outcomes of acute coronary syndromes: The GRACE study

tor rates, would the use of evidence-based therapies in patients with acute myocardial infarction (AMI) increase? Methods: The current project, implemented in five hospitals, was modeled after the previous Guidelines Applied in Practice (GAP) project, but with greater emphasis on tool use. This allowed early identification of barriers to tool use and strategies to overcome barriers. Main outcome measures were AMI quality indicators in pre-measurement (January 1, 2001, to June 30, 2001) and post-measurement (December 15, 2001, to March 31, 2002) samples. Results: One or more tools were used in 93% of patients (standard ORDERS⫽82%, and discharge DOCUMENT⫽47%). Tool use was associated with significantly higher adherence to most discharge-quality indicator rates with increases in aspirin, angiotensin-converting enzyme (ACE) inhibitors, smoking cessation and dietary counseling. Patients undergoing coronary artery bypass grafting (CABG) had lower rates of discharge indicators for ACE inhibitors and lipid-lowering therapy. Patients undergoing percutaneous coronary revascularization were more likely to receive evidence-based therapies. Conclusions: These data validated results of the initial GAP pilot project, namely that quality of AMI care can be improved through the use of guideline-based tools. Identifying and overcoming barriers to tool use led to substantially higher rates of tool use. Perspective: This study demonstrates that the implementation of tools of AMI care was increased across five hospitals when a major emphasis was placed on monitoring and increasing their utilization. Use of care tools was associated with increases in adherence to the key quality-of-care indicators for AMI care. Together with previous reports, the results suggest that the routine use of care tools is an effective method of reminding caregivers and patients regarding key priorities in AMI treatment. The low rates of adherence to quality indicators in patients undergoing CABG suggest that these patients should be particularly targeted for quality-improvement efforts. DM

were analyzed. The composite end point included death, in-hospital MI and stroke. Results: Patients who were already taking statins when they presented to the hospital were less likely to have ST-segment elevation (odds ratio [OR], 0.79 [95% CI, 0.71 to 0.88]) or MI (OR, 0.78 [CI, 0.70 to 0.86]). Patients who continued to take statins in the hospital were less likely to experience complications or to die than were patients who never received statins (OR, 0.66 [CI, 0.56 to 0.77]). Patients not previously taking statins who began statin therapy in the hospital were less likely to die than were patients who never received statin therapy (OR, 0.38 [CI, 0.30 to 0.48]). However, adjustment for the hospital of admission attenuated the association between initiation of statin therapy and the composite end point (OR, 0.84 [CI, 0.65 to 1.10]). Conclusions: The authors concluded that statin therapy can modulate early pathophysiologic processes in patients with ACS. Perspective: The results of this contemporary multinational registry of more than 19,000 patients with ACS suggest that previous statin therapy significantly affects the severity of hospital presentation and that previous or early statin therapy favorably affects clinically relevant hospital outcomes. These data support the hypothesis that statin therapy can modulate pathophysiologic processes in patients with ACS. This could occur through plaque stabilization, pacification of other vulnerable plaques; and/or through effects on thrombogenicity or microvascular response to injury. Future randomized trials evaluating the effect of early statin therapy on clinical outcomes in patients with ACS are needed to more systematically address this question. DM

Clopidogrel Versus Aspirin for Secondary Prophylaxis of Vascular Events: A CostEffectiveness Analysis Schleinitz MD, Weiss JP, Owens DK. Am J Med 2004;116:797– 806. Study Question: Clopidogrel is somewhat more effective than aspirin in preventing recurrent vascular events, but concerns about its cost-effectiveness have limited its use (relatively high cost for marginal benefit). The investigators evaluated the cost-effectiveness of clopidogrel and aspirin as secondary prevention in patients with cardiovascular diseases. Methods: The investigators constructed Markov models assuming a societal perspective and based their analyses on the lifetime treatment of a 63-year-old patient facing event probabilities derived from the Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events (CAPRIE) trial as the base case. Outcome measures included costs, life expectancy in quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and events averted. Results: In patients with peripheral arterial disease, clopidogrel increased life expectancy by 0.55 QALYs at an incre-

Association of Statin Therapy With Outcomes of Acute Coronary Syndromes: The GRACE Study Spencer FA, Allegrone J, Goldberg RJ, et al., for the GRACE investigators. Ann Intern Med 2004;140:857– 66. Study Question: Statins administered early in patients with acute coronary syndrome (ACS) lead to reductions in recurrent ischemic events. Investigators examined the association between previous and early in-hospital statin therapy and the presentation and outcomes of an ACS. Methods: The study was a cohort design with 94 hospitals in 14 countries participating in the Global Registry of Acute Coronary Events (GRACE). A total of 19,537 patients with an ACS were studied. Statin use before and after presentation with an ACS and associated rates of myocardial infarction (MI), hospital complications, and hospital mortality

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