Treatment of Osteoarthritis PowerPoint Presentation

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1 Acute Coronary Syndromes and the Role of Critical Pathway Christopher Cannon, M.D. Brigham and Women’s Hospital Boston

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2 Aspirin and Thrombolysis in Acute MI % of Patients 35 Day Mortality Placebo Aspirin SK Aspirin + SK

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3 TIMI 2: Effect of Time to Treatment <1 h 1-2 h 2-3 h 3-4 h % of Patients *P=0.05 1 hour faster treatment = 10 lives saved per 1000 patients treated 6 Week Mortality 3.2* 3.7 5.2 6.2

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62 31 TIMI 1: Reperfusion Occluded arteries 0 20 40 60 80 % of Patients t-PA SK *P<0.001 Improving Thrombolysis: t-PA vs. SK TIMI Study NEJM 1985;312:397-401. GUSTO 1: Mortality 7.3 6.3 GUSTO Inv. NEJM 1993; 329:673-682. *P<0.001

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5 Thrombolysis vs. Primary Angioplasty % of Patients Weaver WD, JAMA 1997; 278:2093-2098. Schomig A, N Engl J Med 2000; 343:385-91 30 Day Mortality Thrombolysis PTCA t-PA Stent + IIb/IIIa

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6 Medical Treatment After MI % of Patients ISIS-1 Lancet 1986; 2:57-66; HOPE N Engl J Med 2000; 4S. Lancet 1994; 344:1383-1389. Mortality During Follow-up

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ACUTE MI GUIDELINES 11/96 Drug Rx Peri MI: Meta-Analyses NEJM 335:1662, 1996

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8 Continuing Ischemia/Other Clinical High-Risk Features Bed rest + continuous ECG monitoring 02 to maintain Sa02 >90% NTG IV -Blockers, oral (+IV if high risk) Morphine IV for pain IABP if ischemia or BP ACEI for HTN or  LVEF (possibly all patients) Braunwald et al. J Am Coll Cardiol. 2000;36:970-1062. Class I Recommendations for Anti-Ischemic Therapy UA/NSTEMI 9/00

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9 Aspirin + IV heparin + IV platelet GP IIb/IIIa antagonist Aspirin + Subcutaneous LMWH or IV heparin Possible ACS Likely/Definite ACS Definite ACSWith Continuing Ischemia or Other High-Risk Features† or Planned PCI Aspirin * Clinical data on the combination of LMWH and platelet GP IIb/IIIa antagonists are lacking. Their combined use is not currently recommended. † High-risk features were previously listed; others include diabetes, recent MI, and elevated cardiac TnT or Tnl. Braunwald et al. J Am Coll Cardiol. 2000;36:970-1062. Class I Recommendations for Antithrombotic Therapy* UA/NSTEMI 9/00

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10 Class I Recommendations: Early Invasive Strategy 1. Early invasive strategy in patients with UA/NSTEMI and any of the following high-risk indicators: a. Recurrent angina/ischemia at rest or with low-level activities despite intensive anti-ischemic rx b. Recurrent angina/ischemia with CHF symptoms, S3 gallop, pulmonary edema, worsening rales, or new or worsening MR c. High-risk findings on noninvasive stress testing d. Depressed LV systolic function e. Hemodynamic instability f. Sustained VT g. PCI within 6 months h. Prior CABG 2. In the absence of these, either an early conservative or an early invasive strategy in hospitalized patients without contraindications for revascularization Braunwald et al. J Am Coll Cardiol. 2000;36:970-1062.

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11 Class I Recommendations: Risk Factor Modification 1. Smoking cessation and achievement or maintenance of optimal weight, daily exercise, and diet 2. HMG-CoA reductase inhibitors for LDL >130 mg/dL 3. Lipid-lowering agent if LDL after diet is >100 mg/dL 4. Hypertension control to a blood pressure of >130/85 mm Hg 5. Tight control of hyperglycemia in diabetes Braunwald et al. J Am Coll Cardiol. 2000;36:970-1062. UA/NSTEMI 9/00

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Implementation of AHCPR Guidelines for Unstable Angina in 1996: Unfortunate Differences Between Women and Men Results from the GUARANTEE Registry ARANTEE GU

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Global Unstable Angina Registry ANd Treatment Evaluation ARANTEE GU

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Adjusted P value Medical Management ARANTEE GU

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Adjusted P value Catheterization / Revascularization ARANTEE GU

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Adjusted P value Medical Management Age ARANTEE GU

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Adjusted P value Medical Management Non-Q wave MI vs. Unstable Angina ARANTEE GU

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Women Pre Guideline TIMI III Registry Stone PH et al. JAMA 1996;275:1104; Scirica 1999 AHJ Post Guideline ARANTEE GU Comparing Pre- to Post-: Men Women P values : ASA 0.30 0.05 Heparin 0.13 0.001 B-blocker 0.001 0.001

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Aspirin within 24 hours Weeks post discharge % survival 94% 78% P = .002 Giugliano RP,et al. Arch Intern Med 2000;160.

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Heparin within 24 hours Weeks post discharge % survival 93% 85% P = .06 Giugliano RP,et al. Arch Intern Med 2000;160.

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Unadjusted One Year Survival Weeks post discharge Percent surviving 95% 81% P = .0001 Giugliano RP,et al. Arch Intern Med 2000;160.

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N=84,423 NRMI-2: Distribution of Door-to-Needle Times 40% Cannon CP ACC 2000

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24 Baseline Characteristics 0-30 31-60 61-90 >90 P value No. Pts 28,176 33,635 11,531 10,244 Age (mean) 61.2 63.5 65.1 65.7 <0.0001 Female (%) 26 34 39 42 <0.0001 Non-white (%) 13 14 16 19 <0.0001 DM (%) 16 20 23 27 <0.0001 Prior MI (%) 16 19 21 21 <0.0001 Anterior (%) 32 34 37 41 <0.0001 HMO (%) 14 13 12 11 <0.0001 Urban Hosp 87 88 87 86 0.0005 Pre-hosp ECG 7 4 3 3 <0.0001 Onset-door (hr) 1.4 1.7 1.9 2.0 <0.0001 (Median) Door-to-needle time (mins)

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Cannon CP ACC 2000 NRMI-2: Thrombolysis Door-to-Needle Time vs. Mortality N=28,624 33,867 11,616 10,316 P=0.01 P=0.0001 P=NS 1.03 1.11 1.23

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P=0.01 P=0.0007 P=0.0003 P=NS P=NS 1.14 1.15 1.41 1.62 1.61 N=2,230 5,734 6,616 4,461 2,627 5,412 NRMI-2: Primary PCI Door-to-Balloon Time vs. Mortality Cannon CP, et al JAMA 2000;283:2941-2947.

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N=27,080 NRMI-2: Primary PCI Distribution of Door-to-Balloon times Door-to-Balloon Time (minutes)

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US News and World Report30-day mortality by hospital category* * 25th, 50th and 75th percentile for each category

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29 US News and World Report Aspirin in ideal candidates

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30 US News and World Report Beta-blockers in ideal candidates

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30-day MortalityUS News Top-ranked vs Other Hospitals * Adjusted for patient, hospital and physician characteristics Odds ratio

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32 Quality implications The lower mortality observed in “America’s Best Hospitals” appear to be explained in part by their higher use of aspirin and beta-blockers Any hospital can be one of “America’s Best” by increasing their use of aspirin and beta-blockers

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EUROASPIRE II European Action on Secondary and Primary Prevention through Intervention to Reduce Events Euro Heart Survey Programme European Society of Cardiology-ESC  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

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% reaching goal* at interview among those using lipid-lowering medication by center EUROASPIRE * total cholesterol < 5 mmol/l Therapeutic control of total cholesterol at interview  European Society of Cardiology ESC

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% aspirin/other anti-platelets at interview by center EUROASPIRE  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

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% beta-blockers at interview by center EUROASPIRE  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

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Conclusions EUROASPIRE II EUROASPIRE A high prevalence of unhealthy lifestyles, modifiable risk factors and inadequate use of prophylactic drug therapies is found in coronary patients across Europe Considerable potential to raise the standard of preventive cardiology exists throughout Europe in order to reduce coronary morbidity and mortality  European Society of Cardiology ESC Wood et al. Lancet 2001; 357: 995-1001

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National Heart Attack Alert Program (NHAAP) CRITICAL PATHWAYS FOR THE TREATMENT OF PATIENTS WITH ACUTE CORONARY SYNDROMES

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39 Critical Pathways - Definitions Standardized protocols for care Strict definition Full list of all tasks, tracks variances Broader definition Includes clinical protocols (NHAAP 4D’s) Diagnostic pathways - Chest Pain Centers Treatment pathways - Thrombolysis

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40 Goals of Critical Pathways Increase use of recommended medical therapies (e.g., aspirin) Decrease use of unnecessary tests. Decrease hospital length of stay Increase participation in clinical research Improve patient care and decrease costs.

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41 Need and Rationale for Critical Pathways Underutilization of recommended medications (e.g. Aspirin) Overutilization of procedures Length of stay, # ICU days Quality of care measures (door-to-drug, door-to-balloon times)

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42 Development And Implementation Of Critical Pathways Identify problems ( practice variation) Identify working committee/task force to develop path Distribute draft Critical Pathway to all personnel and departments involved. Revise based on approach. Implement pathway Collect and monitor data on pathway performance. Modify the pathway as needed to further improve performance.

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43 Methods of Implementation of Pathways Specific case manager for each Pt High compliance, high cost Standardized order sheets, Pocket guides “Championing” - Grand rounds Recent study -> similar improvements in care with either formal or simpler pathways (Holmboe, ES et al. Am J Med 1999;107:324-31.)

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44

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45 Goal: < 30 Minutes NHAAP Ann Emerg Med 1994;23:311-29.

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W. Rogers, personal communication

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47 Speeding Time to Treatment: Brigham and Women’s Hospital Acute MI Critical Pathway in ED Pt. with Chest Pain. ED Arrival Time Obtain ECG. Assess for ST Elevation Assess for Contraindications to Thrombolysis: Active Bleeding Prior Stroke Confirmed BP > 190/110 Major Surgery <2 Mos. Other Major Illness (cancer, etc.) Mix and Give Thrombolytic: Double-Bolus r-PA Primary PCI: 1. Patient with high stroke/bleeding risk Cardiogenic shock (All patients) Door-to-Drug Time Goal: <30 Mins NO YES 10 mins 10 mins 10 mins _ _ : _ _ Door _ _ : _ _ Data _ _ : _ _ Decision _ _ : _ _ Drug o Cannon CP et al. J Thromb Thrombolysis 1994;1:27-34.

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BWH Thrombolysis Critical Pathway: Effect on Door-to-Drug times Door-to-Drug Time Pre- Post-Pathway Cannon CP, Clin Cardiol 1999;22:17-22

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49 BWH Thrombolysis Critical Pathway: Initial Experience *P=0.013 Cannon CP, et al. Clin Cardiol 1999;22:17-22 BEFORE

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PAMI II: Early Discharge Critical Pathway for Low-Risk MI Patients treated with Primary Angioplasty 6 month outcomes Early D/C Standard P value (%) (%) Death 0.8 0.4 NS MI 0.8 0.4 NS Unstable Angina 10.1 12.0 NS D/MI/UA/CHF/stroke 15.2 17.5 NS Length of stay (days) 4.2 7.1 p<0.001 Hospital Costs $9,658 $11,604 p=0.002 + 5,287 + 6,125

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53 BWH ED Checklist Orders for UA/NSTEMI UA/NSTEMI Hx. Good Story and/or + ECG, or + CKMB/TnI Hx MI, PCI/CABG Tests  CBC, CMP, PT/PTT CK-MB, TnI  Lipid profile Meds  ASA 325mg chew  Metoprolol IV/PO  Discuss with Cards B - Heparin IV + IIb/IIIa - Enoxaparin SQ - Cath Lab  NTG PRN

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54 Effect of Critical Pathway on Median Length of Stay

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55 CHAMP Program to improve Secondary Prevention Jan 1992- Dec 1995 N=256 pre- and 302 post Pre-CHAMP post-CHAMP D/C 1 yr D/C 1 yr ASA 78% 68% 92% 94% B-blocker 12% 18% 61% 57% ACE 4% 16% 56% 48% Statin 6% 10% 86% 91% LDL <100 6% 58% Fonarow GC et al. Am J Cardiol 2001;87:819-822.

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56 Conclusions Critical pathways hold great promise to improve Quality of care, Clinical outcomes Cost-effectiveness Initial studies show better quality of care and suggest improved outcomes