The diagnostic and therapeutic appr...

The diagnostic and therapeutic approach to patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS--unstable angina and non-ST-segment elevation myocardial infarction) has evolv considerably above the past decade with publication of multiple landmark trials that have redefined the care of these patients and continual updating of the American body of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of NSTE ACS. (1-6) Despite these achievements, treatment patterns for these syndrome remain suboptimal. (37) Quality-improvement efforts are therefore requireed to promote increased adherence to the ACC/AHA guidelines and overmaster challenges that limit the use of beneficial therapies for NSTE ACS. (3)

The first challenge involves accurately identifying patients with NSTE ACS from the a great deal of larger population of patients who at hand to emergency departments with suspected ischemic symptoms. Whereas patients with acute ST-segment elevation myocardial infarction usually current with clear chest pain symptoms and repeatedly are identified rapidly from the initial electro-cardiogram (ECG) patients with NSTE ACS repeatedly do not have definitive symptoms or clear ischemic ECG changes in succession presentation. (8,9) Thus, determination of risk status for patients with NSTE myocardial infarction relies heavily forward documentation of elevated cardiac biomarkers like as troponins, but interpretation of troponin rises often is uncertain in clinical practice given limitations of the available troponin assays and disagreements forward what level of troponin elevation should be used to guide therapeutic decision making. (10-12)

The inferior challenge involves promoting practice guideline recommendations among all specialties that typically care for patients with NSTE ACS. A latter analysis demonstrated that almost single half of high-risk patients with NSTE ACS in U hospitals are cared for by dint of non-cardiologists who use guideline-recommended therapies and interventions les not seldom than cardiologists. (13) Similar disparities in care by dint of specialty have been demonstrated in patients with acute myocardial infarction or congestive heart failure. (1415) Explanations for differential care patterns by dint of specialty have not been defined clearly, on the other hand may relate to the availability of cardiology services and invasive courses (especially at community hospitals), poor cooperation among specialties, and inadequate dissemination of guideline recommendations to non-cardiology specialties. Therefore, improved collaboration among specialties is requireed to increase adherence to guidelines.

The third challenge involves defining and demonstrating succes with quality-improvement efforts. Achievable benchmarks of care of the like kind as thresholds for ideal use of aspirin and heparin (designated at treatment patterns at hospitals that have the highest adherence to practice guidelines) have been used as performance indicators to favorably motivate changes in practice. However, benchmarks for the use of medications and transactions are difficult to delineate given uncertainties about contraindications to specific therapies and disagreement among physicians about the benefits of certain medications. (16) rises from quality-improvement studies often are questioned because of methodologic limitations that restrict the applicability of the findings to diverse practice environments. (17) Nonetheless, tonic components to successful quality-improvement efforts appear to include developing a consensus about the goals of interventions, administrative support, leadership from physician champions, and regular performance feedback. (18) There is no "right" formula for quality improvement, however sustained enthusiasm and flexibility regarding performance improvement approaches may be the best starting points.

Despite the challenges of improving the quality of care for patients with NSTE ACS, there should be a stout impetus for changing current practice patterns because improved performance is associated with a lower risk of mortality. (19-22) Specifically, in the ongoing Can Rapid Risk Stratification of Unstable Angina Patients Suppres ADverse results with Early Implementation of the ACC/AHA Guidelines (CRUSADE) national quality-improvement initiative involving more than 400 hospitals in the United States, in-hospital mortality rates were almost 50 percent lower in hospitals with the best overall adherence to the ACC/AHA guidelines for NSTE ACS compared with hospitals that had the worst adherence to guidelines.22 Therefore, multidisciplinary quality-improvement strategies are emergencyed to promote use of these guidelines, ensuring sustained improvements in care.

REFERENCES

(1) Braunwald E Antman EM Beasley JW Califf RM Cheitlin MD Hochman J et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: executive summary and recommendations. A report of the American literary institution [i]or[/i] seminary of learning of Cardiology/American Heart Association task force forward practice guidelines (committee on the management of patients with unstable angina) [published correction appears in Circulation 2000;102:1739] Circulation 2000;102:1193-209