GRACE Overview

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 8 advisors 40 subsite cardiologists „European‟ clusters Chair: KAA Fox 8 advisors 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 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 13 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 18 advisory committee members 3 ~100 hospitals ~10,000 ACS patients/year 4 5 6 Multinational Site Network Argentina Australia Belgium Brazil Canada France 6 sites 6 sites 6 sites 7 sites 5 sites 7 sites Germany Italy 5 sites 5 sites New Zealand 2 sites Poland Spain UK USA 6 sites 3 sites 5 sites 18 sites 81 Active Core Study Sites: 16 Clusters in 13 Countries Status of 16 Core Clusters  60,723 cases enrolled  85% six-month follow-up Q3-2006 The “Big Picture” Core GRACE & GRACE2 GRACE Core Substudy 1 Substudy 3 Substudy 2 GRACE Core 60,723 patients 81 hospitals 13 countries GRACE2 24,513 patients 153 hospitals 23 countries 234 Core GRACE & GRACE2 Study Sites in 29 Countries* *29 countries = 17 GRACE2 + 6 core GRACE + 6 both Status: September 30, 2006 81 Core & 153 Expanded Sites  29 countries  234 hospitals  85,236 cases Q3-2006 Internet Website www.outcomes.org/grace Hospital Characteristics Q4-2001 vs. Current Quarter Q4-2001 Q3-2006 Number of Hospitals Coronary care unit Emergency department Cardiac catheterization laboratory Open heart surgery Hospital beds (mean) Coronary care unit beds (mean) ACS admissions (mean, per year) Q3-2006 109 94% 86% 65% 43% 416 10 487 81 99% 91% 74% 51% 555 11 640 60,723 Cases Enrolled as of September 30, 2006 70000 60000 Cases Received Initial CRF 6-Month Follow-up 55454 46945 43117 38444 28699 19453 11543 6689 2411 233 13245 20303 27618 35301 58866 60723 57406 45106 46521 48045 50000 40000 30000 20000 10000 0 1999 2000 2001 2002 2003 2004 2005 Q1-06 Q2-06 Q3-06 Quarter-Year Q3-2006 Classification of Cases 40% 34% 30% 29% 30% Patients (%) 20% 10% 7% 0% STEMI Q3-2006 UA NSTEMI Other Hospital Discharge Status STEMI Death Home NSTEMI 4% 78% UA 3% 87% 8% 77% Transfer * Other 9% 6% 11% 6% 9% 2% *Transfer to another acute care hospital. Q3-2006 Admission versus Final Diagnosis UA N=4999 (44%) MI N=4100 (36%) „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) 68 66 56 32 15/14 57 28 62 47 7 UA (12,509) 66 64 78 41 25/19 55 26 66 54 Hospital Treatment According to Admission Diagnosis n MI 16,304 UA 15,266 ? MI 3,474 Chest pain 3,266 % ACE inhibitors Aspirin -blockers Ca2+ blockers Gp IIb/IIIa: no PCI Gp IIb/IIIa with PCI LMWH UFH Thrombolytic agents 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 NSTEMI UA 80% 78% 69% 58% 73% 60% 47% Procedures (%) 60% 40% 25% 20% 0% LVEF Echo Stress test 18% 17% Hospital Cardiac Interventions According to Final Diagnosis Intervention n STEMI 13,862 % 62 NSTEMI UA 11,316 12,509 % 57 % 49 Cardiac catheterization PCI CABG 45 4 31 7 23 6 Treatments at Discharge STEMI 13,862 % 67 92 78 10 63 8 n ACE inhibitors Aspirin -blockers Ca2+ blockers Statins Warfarin NSTEMI 11,316 % 56 89 76 20 59 7 UA 12,509 % 52 88 72 31 57 7 Hospital Outcome by Final Diagnosis 20 STEMI (13,862) NSTEMI (11,316) UA (12,509) Patients (%) 15 10 8 5 4 5 3 3 2 1.3 0.9 0.5 Stroke 0 Death Major Bleed Hospital Outcomes 12 <0.0001 10.7 Elderly patients (>=75) Younger patients (65-<75) Patients (%) 8 5.6 5.6 <0.0001 4 4.0 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 1.1 66.9 2.2 29.7 US (%) 327 17.7 30.6 18.7 33.0 AB (%) 339 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 Prior CABG History of diabetes History of congestive heart failure Presentation without chest pain *Age 75 years *As compared to the <55 years age group Eagle KA et al. Lancet 2002;359:373-7. OR (95% CI) 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) Geographical Variation: Admission to Hospitals with/without Access to Cath Lab 100 80 80 Cath lab No cath lab 78 61 82 Patients (%) 60 40 20 20 0 USA Europe ANC AB 39 22 18 ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil 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 80 United States Australia/New Zealand/Canada Europe Argentina/Brazil 92 92 91 95 Patients (%) 65 58 39 60 40 20 0 PCI GP IIb/IIIa 37 30 24 17 8 15 9 13 33 LMWH ASA Budaj A et al. Am Heart J 2003;146:999-1006. Antithrombotic Rx Used None 18% UFH 30% LMWH + llb/IIIa 2% UFH + llb/IIIa 4% LMWH 46% Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592. Incidence of Major Bleeding 9 UFH LMWH UFH + IIb/IIIa LMWH + IIb/IIIa 8.3 Patients (%) 6 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 UFH + IIb/IIIa LMWH + IIb/IIIa 0 0.5 Lower 1 2 3 3.9% OR=0.55 P<0.001 OR=2.26 2.4% 8.3% 2.9% Higher Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592. Safety Events 3 UFH LMWH UFH + IIb/IIIa LMWH + IIb/IIIa 2.9 Patients (%) 2 1.5 1.2 1 0.3 0.1 0 0.7 0.6 0.6 0.7 0 Stroke 0 0 ICH  Plts Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592. Major Cardiac Events 15 UFH LMWH UFH + IIb/IIIa LMWH + IIb/IIIa 11.3 9.9 13.8 12.4 10.6 Patients (%) 10 5 5 6.3 6.6 4.4 2.9 2.9 5 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 Incidence of Major Bleeding 6 5 Overall NSTEMI 3.9 UA STEMI 4.7 4.8 % of Patients 4 3 2.3 2 1 0 Major Bleed Moscucci M et al.Eur Heart J 2003;24:1815-23. Predictors of Major Bleed Variables Age (per 10 year ↑) Female gender History of renal insufficiency History of bleeding Killip Class IV MAP (per 20 mmHg ↓) IV Inotropics Overall x x x x x x UA x x x STEMI x x x x x NSTEMI x x x 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 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. In-Hospital Mortality Rates 50 40 No Major Bleed Major Bleed Patients (%) 30 20 10 0 5.1 ** 18.6 ** 16.1 ** 15.3 5.3 ** 22.8 7.0 3.0 Unstable Angina Overall **P<0.001 NSTEMI STEMI Moscucci M et al.Eur Heart J 2003;24:1815-23. 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 Therapy ASA B blocker ACE-I Reperfusion GP IIb/IIIa/LMWH % of pts who are (n=2,501) (n=2,504) (n=3,631) eligible X X X X X X Granger CB et al. J Am Coll Cardiol 2001;37(2 Suppl A):503A. ST  MI Non- ST  MI UA X X X X GRACE: Use of EBM in “Eligible” Patients 100% 93% 89% 81% 71% 64% 57% In-hosp Discharge 80% 70% % Ideal Use 60% 14% PTCA 58% 40% 14% IIb/IIIa 20% 56% lytics 48% LMWH 0% ASA B-blocker ACE-I Reperf LMWH/IIb/IIIa n=5,373 n=4,480 n=3,254 n=1,963 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 100 80 Patients (%) United States Australia/New Zealand/Canada Europe Argentina/Brazil 57 50 94 93 94 93 60 47 40 49 54 53 53 26 20 0 **P<0.01 ACE Statin AT/AC AT/AC, antithrombin or anticoagulant Fox KAA et al. Eur Heart J 2002;23:1177-89. Increase in Diagnosis of MI Utilizing Troponin 30 26 25 20 15 15 10 5 0 Troponin + in addition to CK  ULN Troponin + in addition to CK  2 x ULN Troponin + in addition to CK-MB  ULN % Increase in Patients with MI n=3420 of 8213 with CK, CK-MB & troponin measurements 9 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 * 6 (3.3 - 10.1) Odds Ratio n=900 4 3* n=124 2.1 (1.6 - 5.7) 2 (0.6 - 7.4) 0 CK  2 x ULN Troponin– CK  2 x ULN Troponin + CK > 2 x ULN Troponin– CK > 2 x ULN Troponin + *p<0.05 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 80 77.8 74.5 70.3 69.5 Australia/New Zealand/Canada Europe South America USA Percentage 60 40 25.4 20 0 Hx of CAD (n=4974) No Hx of CAD (n=6414) Prior long-ASA use according to geographic region and history 18.1 18.5 18.3 Type of ACS and Hospital Mortality in Patients with History of CAD Stratified By Prior ASA 80 Prior ASA 60 No prior ASA 58 45 40 26 20 15 3 0 STEMI NSTEMI UA Death *Controlled for age, sex, medical hx, prior therapies, in hospital therapies  Impact of prior ASA on: – STEMI 0.52 (0.44,0.61)* – Death 0.69 (0.5,0.95)** 7 28 29 **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 44 40 31 25 20 5 0 STEMI NSTEMI UA Death *Controlled for age, sex, medical hx, prior therapies, in hospital therapies  Impact of prior ASA on: – STEMI 0.35 (0.30,0.40)* – Death 0.77 (0.55,1.07)** 6 27 23 ** 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 14000 No Hospital Statins N/N 12000 10000 8000 6000 4000 2000 0 Prior Statins No Prior Statins N/Y N/Y Y/Y Ann. Intern Med. 2004;140:856-866. Final Diagnosis of ACS Patients According to Previous Treatment with Statins St elevation MI* 100 80 non-ST elevation MI Unstable angina Patients, % 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 3 3.5 4 Odds Ratio Am J Cardiol 2003;92(9):1031-6 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 2 2.5 Odds Ratio 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 Admission on Hospital Mortality >75 years 3.1 (2.4,3.9) 3.3 (2.3,4.8) 5.0 (2.9,8.3) 65-74 years 55-64 years <55 years 1 Lower odds ratio for death *Relative to patients without HF 10.1 (5.3,19.2) 10 Higher odds of death 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 All patients STEMI Non-STEMI HF (+) 12.0% 16.5% 10.3% HF (-) 2.9% 4.1% 3.0% Unstable angina 6.7% 1.6% 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 6.7% +GP –stent 12.8% -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 8.7% +GP –stent 7.4% -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 Death 5% (480/9414) NSTEMI 6% (496/7977) UA 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 16.2 14.7 15.7 STEMI (5,476) NSTEMI (5,209) UA (6,149) Patients (%) 15 10 9.3 8.0 8.3 5.0 7.1 6.1 5 0 Cardiac cath PCI CABG Goldberg RJ et al.Am J Cardiol 2004;93:288-93. 6 Month Follow-up 30 25 UFH LMWH UFH + IIb/IIIa LMWH + IIb/IIIa 27.6 23.1 18.1 19.7 18.5 19.0 Patients (%) 20 15 10 5 0 12.2 5.8 6.4 7.8 4.1 5.7 Death MI Rehosp Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592. Total Outcomes: Admission to 6 Months 30 Patients (%) STEMI (2075) NSTEMI (1856) UA (2883) 20 17 20 20 12 13 8 3 3 1.5 10 0 Death Stroke Urgent readmission for cardiac event Survival Rate 6 Months Post Discharge for STEMI, NSTEMI, and UA Patients 100 90 % Surviving 80 70 60 50 0 1 STEMI Non-STEMI UA 2 3 4 5 6 Months after hospital discharge Goldberg RJ et al.Am J Cardiol 2004;93:288-93. Factors Associated With An Increased Risk of Post-Discharge Death Characteristic Age (yrs) 65-74 >75 Medical history HF MI TIA/Stroke Hospital complications Cardiogenic shock HF Stroke 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 2.21 1.61-3.04 1.69 1.28-2.22 2.20 1.71-2.84 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 Medical history HF MI PCI Hospital complications Cardiogenic shock HF HR 3.34 5.29 2.23 1.44 0.52 95% CI 1.81-6.19 2.88-9.72 1.61-3.08 1.09-1.91 0.35-0.77 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 50% 40% Non-STE MI UA Patients (%) 30% 20% 10% 0% 1999 (n=5513) 2000 (n=8787) 2001 (n=8934) 2002 (n=8944) 2003 (n=5924) Year of Discharge Temporal Trends STEMI: In-hospital Therapies 60 LMWH Ticl/Clop GPIIb/IIIa* Patients (%) 40 20 0 Jul-Dec 1999 Jan-Jul 2000 Jul-Dec 2000 Jan-Jul 2001 Jul-Dec 2001 Year of Treatment *without PCI Fox KAA et al. Eur Heart J 2003;24:1414-24. Temporal Trends STEMI: Reperfusion 60 Lytics Primary PCI* No reperfusion Patients (%) 40 20 0 Jul-Dec 1999 Jan-Jul 2000 Jul-Dec 2000 Jan-Jul 2001 Jul-Dec 2001 Year of Treatment *within 12 h Fox KAA et al. Eur Heart J 2003;24:1414-24. Temporal Trends NSTEMI: In-hospital Therapies 80 LMWH Ticl/Clop GPIIb/IIIa Patients (%) 60 40 20 0 Jul-Dec 1999 Jan-Jul 2000 Jul-Dec 2000 Jan-Jul 2001 Jul-Dec 2001 Year of Treatment Fox KAA et al. Eur Heart J 2003;24:1414-24. 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 2006) 100% 80% Accepted (%) Overall rate = 59% 77% Number of abstracts accepted = 94 60% 40% 20% 0% ESC 57% 43% ACC AHA Manuscript Status Published/in press Provisionally accepted Submitted Being revised following submission Edit/write assistance Top priority independent Medium priority Low priority 46 1 8 7 12 7 7 5 0 10 20 30 40 50 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