global registry of acute coronary events assessing todays practice patterns to enhance tomorrows...

Global Registry of Acute Global Registry of Acute Coronary EventsCoronary Events

Assessing Today’s Practice Patterns to Assessing Today’s Practice Patterns to Enhance Tomorrow’s CareEnhance Tomorrow’s Care

Supported by an unrestricted educational grant from Supported by an unrestricted educational grant from sanofi-aventis to the Center for Outcomes Research sanofi-aventis to the Center for Outcomes Research

University of Massachusetts Medical SchoolUniversity of Massachusetts Medical School

What is GRACE?What is GRACE?

Global Registry of Acute Coronary EventsGlobal Registry of Acute Coronary Events Largest multinational registry covering the full Largest multinational registry covering the full

spectrum of ACSspectrum of ACS Generalizable patient inclusion criteria Generalizable patient inclusion criteria In-hospital and 6-month follow-upIn-hospital and 6-month follow-up Representative of the catchment population: Representative of the catchment population:

(clusters of hospitals)(clusters of hospitals) Full spectrum of hospitals and facilitiesFull spectrum of hospitals and facilities Training, audit and quality controlTraining, audit and quality control

International Scientific International Scientific Advisory CommitteeAdvisory Committee

International Advisory CommitteeInternational Advisory Committee

‘Americas’ clustersChair: JM Gore

‘Americas’ clustersChair: JM Gore

‘European’ clustersChair: KAA Fox

‘European’ clustersChair: KAA Fox

8 advisors8 advisors 8 advisors8 advisors

40 subsite cardiologists




Scientific Advisory CommitteeScientific Advisory Committee

ArgentinaArgentina Enrique GurfinkelEnrique GurfinkelAustralia/New ZealandAustralia/New ZealandDavid BriegerDavid BriegerAustriaAustriaGeorg GaulGeorg GaulBelgium Belgium Frans J Van de WerfFrans J Van de WerfBrazil Brazil Álvaro AvezumÁlvaro AvezumCanada Canada Shaun GoodmanShaun Goodman

Germany Germany Dietrich C GulbaDietrich C GulbaItalyItalyGiancarlo AgnelliGiancarlo AgnelliFranceFranceGilles MontalescotGilles MontalescotPh Gabriel StegPh Gabriel StegPolandPolandAndrzej BudajAndrzej BudajSpainSpain José López-SendónJosé López-Sendón

United KingdomUnited KingdomKeith AA FoxKeith AA FoxMarcus FlatherMarcus FlatherUnited StatesUnited StatesFrederick A AndersonFrederick A AndersonKim A EagleKim A EagleRobert J GoldbergRobert J GoldbergJoel M GoreJoel M GoreChristopher B GrangerChristopher B GrangerBrian M KennellyBrian M Kennelly

Co-ChairsCo-Chairs Keith AA Fox, UKKeith AA Fox, UKJoel M Gore, USAJoel M Gore, USA

Publications Publications Kim A Eagle, USAKim A Eagle, USACo-ChairsCo-Chairs Ph Gabriel Steg, FrancePh Gabriel Steg, France

Study Co-ordinationStudy Co-ordination Fred Anderson, University of Massachusetts Fred Anderson, University of Massachusetts

Objectives of GRACEObjectives of GRACE

Identify opportunities to improve the quality Identify opportunities to improve the quality of care for patients with ACSof care for patients with ACS

Describe diagnostic & treatment strategies, Describe diagnostic & treatment strategies, & hospital & post-discharge outcomes& hospital & post-discharge outcomes

Develop hypotheses for future clinical Develop hypotheses for future clinical researchresearch

Disseminate findings to a wider audienceDisseminate findings to a wider audience

Core GRACE Study Design Core GRACE Study Design

~100 hospitals in 14 countries~100 hospitals in 14 countries– Europe, North & South America, Australia, Europe, North & South America, Australia,

New Zealand New Zealand

Population-based clusters with community Population-based clusters with community

hospitals and referral centreshospitals and referral centres

First 10-20 consecutive cases per centre/month: First 10-20 consecutive cases per centre/month:

qualifying symptoms PLUS evidence of CADqualifying symptoms PLUS evidence of CAD

Random audit of all centres: 3 year cycleRandom audit of all centres: 3 year cycle

Cluster Strategy for Study Cluster Strategy for Study Sites: Population-Based DesignSites: Population-Based Design

~100 hospitals~10,000 ACS

patients/year

18 advisorycommitteemembers

18 advisorycommitteemembers

2

3

4

5

6

1

Multinational Site NetworkMultinational Site Network

ArgentinaArgentina 6 sites6 sites

AustraliaAustralia 7 sites7 sites

Austria Austria 6 site6 site

BelgiumBelgium 6 sites6 sites

BrazilBrazil 7 sites7 sites

CanadaCanada 6 sites6 sites

FranceFrance 6 sites6 sites

Germany Germany 5 sites5 sites

Italy Italy 5 sites5 sites

New Zealand New Zealand 2 sites2 sites

Poland Poland 6 sites6 sites

Spain Spain 4 sites4 sites

UK UK 5 sites5 sites

USA USA 18 sites18 sites

89 Active Core Study Sites: 89 Active Core Study Sites: 17 Clusters in 14 Countries17 Clusters in 14 Countries

Status of 17 Core ClustersStatus of 17 Core Clusters

70,359 cases enrolled70,359 cases enrolled

85% six-month follow-up 85% six-month follow-up

Q4-2007

The “Big Picture”The “Big Picture”Core GRACE & GRACECore GRACE & GRACE22

GRACE Core GRACE Core 70,359 patients70,359 patients89 hospitals89 hospitals14 countries14 countries

GRACE CoreGRACE Core

Substudy 1Substudy 2

Substudy 3

GRACEGRACE22 31,982 patients31,982 patients

158 hospitals158 hospitals23 countries23 countries

247 Core GRACE & GRACE247 Core GRACE & GRACE22 Study Sites in 30 Countries*Study Sites in 30 Countries*

*30 countries = 16 GRACE*30 countries = 16 GRACE2 2 + 7 core GRACE + 7 both+ 7 core GRACE + 7 both

Status: December 31, 2007Status: December 31, 200789 Core & 158 Expanded Sites89 Core & 158 Expanded Sites

30 countries30 countries

247 hospitals247 hospitals

102,341 cases102,341 cases

Q4-2007

Internet WebsiteInternet Websitewww.outcomes.org/gracewww.outcomes.org/grace

Hospital CharacteristicsHospital CharacteristicsQ4-2001 vs. Current QuarterQ4-2001 vs. Current Quarter

Q4-2001 Q4-2007Q4-2001 Q4-2007

Number of HospitalsNumber of Hospitals 109 109 89 89

Coronary care unitCoronary care unit 94% 94% 98% 98%

Emergency departmentEmergency department 86% 88%86% 88%

Cardiac catheterization laboratoryCardiac catheterization laboratory 65% 72% 65% 72%

Open heart surgeryOpen heart surgery 43% 45%43% 45%

Hospital beds (mean)Hospital beds (mean) 416 523 416 523

Coronary care unit beds (mean)Coronary care unit beds (mean) 10 11 10 11

ACS admissions (mean, per year)ACS admissions (mean, per year) 487 585 487 585Q4-2007

70,359 Cases Enrolled70,359 Cases Enrolledas of December 31, 2007as of December 31, 2007

2411

11543

19453

28699

38444

56081

62932

70359

48140

54848

27618

20303

36883

13245

6689

44453

233

50441

0

10000

20000

30000

40000

50000

60000

70000

80000

1999 2000 2001 2002 2003 2004 2005 2006 2007Year of Enrollment

Ca

se

s

Initial CRF 6-Month Follow-up

Q4-2007

34%

29%31%

7%

0%

10%

20%

30%

40%

STEMI UA NSTEMI Other

Pat

ien

ts (

%)

Q4-2007

Classification of CasesClassification of Cases

Hospital Discharge StatusHospital Discharge Status

STEMISTEMI NSTEMI UA NSTEMI UA

DeathDeath 7%7% 4%4% 3%3%

HomeHome 77%77% 78%78% 87%87%

Transfer Transfer ** 10%10% 12%12% 9%9%

OtherOther 6%6% 6%6% 2%2%

**Transfer to another acute care hospital.Transfer to another acute care hospital.

Q4-2007Q4-2007

*Missing diagnosis in 236 patients

UAN=4999(44%)

‘Rule-out’ MIN=957(9%)

Unspecified chest pain

N=745(7%)

Other cardiacN=381(3%)

Non-cardiacN=125(1%)

STEMIN=3419(30%)

Non-STEMIN=2893(25%)

Unstable anginaN=4397(38%)

Other cardiacN=508(4%)

Non-cardiacN=326(3%)

MIN=4100(36%)

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.

Admission versus Final Admission versus Final DiagnosisDiagnosis

Fox KAA et al.Eur Heart J 2002;23:1177-89.Fox KAA et al.Eur Heart J 2002;23:1177-89.

Baseline CharacteristicsBaseline Characteristics

STEMI NSTEMI UASTEMI NSTEMI UA (n = 13,862) (11,316) (n = 13,862) (11,316) (12,509)(12,509)

Median age (years)Median age (years) 6565 6868 6666Male (%)Male (%) 7070 6666 6464Prior history (%)Prior history (%)• AnginaAngina 4343 5656 7878• Myocardial infarctionMyocardial infarction 2020 3232 4141• PCI/CABGPCI/CABG 8/58/5 15/1415/14 25/1925/19• SmokingSmoking 6262 5757 5555• Diabetes mellitus Diabetes mellitus 2121 2828 2626• Hypertension Hypertension 5252 6262 6666• Hyperlipidemia Hyperlipidemia 3838 4747 5454Participant in clin trial (%) 11Participant in clin trial (%) 1177 77

Hospital Treatment According Hospital Treatment According to Admission Diagnosisto Admission Diagnosis

MI MI UA UA ? MI? MI Chest painChest painn 16,304 15,266 3,474 3,266n 16,304 15,266 3,474 3,266

%% %% % % % %

ACE inhibitorsACE inhibitors 6969 56 56 5656 55 55

AspirinAspirin 9494 92 92 9292 92 92

-blockers-blockers 8383 81 81 8181 79 79

CaCa2+2+ blockers blockers 1515 34 34 3030 29 29

Gp IIb/IIIa: no PCIGp IIb/IIIa: no PCI 55 4 4 77 7 7

Gp IIb/IIIa with PCIGp IIb/IIIa with PCI 26 11 26 11 1515 18 18

LMWH LMWH 52 6452 64 4040 40 40

UFHUFH 5959 43 43 5151 51 51

Thrombolytic agentsThrombolytic agents 3535 2 2 33 3 3

Diagnostic ProceduresDiagnostic Procedures

78%73%

18%

69%60%

17%

58%

47%

25%

0%

20%

40%

60%

80%

100%

LVEF Echo Stress test

Pro

ced

ure

s (

%)

STEMI NSTEMI UA

Hospital Cardiac Interventions Hospital Cardiac Interventions According to Final DiagnosisAccording to Final Diagnosis

Intervention Intervention STEMI NSTEMI UASTEMI NSTEMI UAn 13,862 11,316 12,509n 13,862 11,316 12,509

%% %% % %

Cardiac catheterization Cardiac catheterization 6262 5757 4949

PCI PCI 4545 3131 2323

CABGCABG 44 77 66

Treatments at DischargeTreatments at Discharge

STEMI NSTEMI UASTEMI NSTEMI UAn 13,862 11,316 12,509n 13,862 11,316 12,509

%% %% % %

ACE inhibitors ACE inhibitors 6767 5656 5252

Aspirin Aspirin 9292 8989 8888

-blockers -blockers 7878 7676 7272

CaCa2+2+ blockers blockers 1010 2020 3131

Statins Statins 6363 5959 5757

Warfarin Warfarin 88 77 77

8

4

1.3

5

3

0.9

32

0.50

5

10

15

20

Death Major Bleed Stroke

Pat

ien

ts (

%)

STEMI (13,862)

NSTEMI (11,316)

UA (12,509)

Hospital Outcome by Hospital Outcome by Final DiagnosisFinal Diagnosis

Hospital OutcomesHospital Outcomes

0

4

8

12

Death Major bleed

Pat

ien

ts (

%)

Elderly patients (>=75)

Younger patients (65-<75)10.7

5.6

4.0

5.6

<0.0001

<0.0001

Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.Lankes W et al.Eur Heart J 2002;23(Abstr Suppl):502.

What proportion of eligible patients What proportion of eligible patients receive reperfusion therapy?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 Missed Opportunities for ReperfusionReperfusion

ST ↑ or LBBB, <12 hrs from onset, no contraindications

ANC (%) US (%) AB (%)EUR (%) n 269 327 339 739

PCI alone 1.1 17.7 13.9 16.2 Lytic alone 66.9 30.6 53.1 49.4 Both 2.2 18.7 5.0 4.9 Neither 29.7 33.0 28.0 29.5

AB, Argentina/Brazil; ANC, Australia/New Zealand/Canada; EUR, Europe; US, United States

Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..

Independent Predictors of Independent Predictors of No ReperfusionNo Reperfusion

Variable OR (95% CI)

Prior CABG 2.28 (1.35 - 3.87)

History of diabetes 1.46 (1.11 -1.94)

History of congestive heart failure 2.92 (1.84 - 4.67)

Presentation without chest pain 2.23 (2.13 - 4.89)

*Age 75 years 2.37 (1.82 - 3.08)

*As compared to the <55 years age group

Eagle KA et al. Lancet 2002;Eagle KA et al. Lancet 2002;359:373-7359:373-7..

80 78

61

82

20 22

39

18

0

20

40

60

80

100

USA Europe ANC AB

Pa

tie

nts

(%

)

Cath lab No cath lab

ANC, Australia/New Zealand/Canada; AB, Argentina/Brazil

Geographical Variation: Geographical Variation: Admission to Hospitals Admission to Hospitals with/without Access to Cath Labwith/without Access to Cath Lab

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.

3733

13

92

178

58

92

30

15

65

91

24

9

39

95

0

20

40

60

80

100

PCI GP IIb/IIIa LMWH ASA

Pat

ien

ts (

%)

United States

Australia/New Zealand/Canada

Europe

Argentina/Brazil

Geographic Practice VariationGeographic Practice Variation

Budaj A et al. Am Heart J 2003;146:999-1006.Budaj A et al. Am Heart J 2003;146:999-1006.

Antithrombotic Rx UsedAntithrombotic Rx Used

LMWH 46%

UFH 30%

UFH + llb/IIIa

4%

LMWH + llb/IIIa

2%

None 18%

Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.Cannon CP et al.Eur Heart J 2001;22(Abstr Suppl):592.

Incidence of Major BleedingIncidence of Major Bleeding

3.9

2.4

8.3

2.9

0

3

6

9

Major bleed

Pat

ien

ts (

%)

UFH

LMWH

UFH + IIb/IIIa

LMWH + IIb/IIIa


Multivariate Adjusted Odds of Multivariate Adjusted Odds of Major HemorrhageMajor Hemorrhage

0 0.5 1 2 3Lower Higher

Major hemMajor hem 3.9%3.9%

2.4%2.4%

8.3%8.3%

2.9%2.9%

UFHUFH

LMWHLMWH

UFH +UFH +IIb/IIIaIIb/IIIa

LMWH +LMWH +IIb/IIIaIIb/IIIa

OR=0.55OR=0.55P<0.001P<0.001

OR=2.26OR=2.26


Safety EventsSafety Events

0.1

0.7

1.2

0

0.6 0.7

0.3

0.6

0 0

2.9

1.5

0

1

2

3

ICH Stroke Plts

Pa

tie

nts

(%

)

UFHLMWHUFH + IIb/IIIaLMWH + IIb/IIIa


Major Cardiac EventsMajor Cardiac Events

5

10.6

2.9

6.65

11.3

13.8

4.4

6.3

2.9

9.9

12.4

0

5

10

15

Death MI Death/MI

Pat

ien

ts (

%)

UFH

LMWH

UFH + IIb/IIIa

LMWH + IIb/IIIa


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 BleedingIncidence of Major Bleeding

3.9

2.3

4.7 4.8

0

1

2

3

4

5

6

Major Bleed

% o

f P

ati

en

ts

Overall UA

NSTEMI STEMI

Moscucci MMoscucci M et al.et al.Eur Heart J 2003;24:1815-23.Eur Heart J 2003;24:1815-23.

Predictors of Major Bleed Predictors of Major Bleed VariablesVariables OverallOverall UAUA STEMISTEMI NSTEMINSTEMI

Age (per 10 year Age (per 10 year ↑)↑) xx xx xx xxFemale genderFemale gender xx xx xxHistory of renal insufficiencyHistory of renal insufficiency xx xx xxHistory of bleedingHistory of bleeding xx xx xx xxKillip Class IVKillip Class IV xxMAP (per 20 mmHg MAP (per 20 mmHg ↓)↓) xx xxIV InotropicsIV Inotropics xx xx xx xx

Other vasodilatorsOther vasodilators xx xx

ThrombolyticsThrombolytics xx xxDiureticsDiuretics xx xx xx xxUnfractionated heparinUnfractionated heparin xx xxIIb/IIIa receptor blockersIIb/IIIa receptor blockers xx xx xxPA cathetersPA catheters xx xx xx xxPCIPCI xx xx xxThrombolytics and IIb/IIIa inhibThrombolytics and IIb/IIIa inhib xx xx xx


5.13.0

5.3 7.0

18.616.1 15.3

22.8

0

10

20

30

40

50

Overall Unstable Angina NSTEMI STEMI

Pa

tie

nts

(%

)

No Major Bleed

Major Bleed

** ****

**P<0.001

In-Hospital Mortality RatesIn-Hospital Mortality Rates

**


Outcome of “Low-risk” Outcome of “Low-risk” Patients with ACSPatients with ACS

Presentation with UA in the absence of dynamic Presentation with UA in the absence of dynamic ECG changes, no troponin elevation, no arrhythmia ECG changes, no troponin elevation, no arrhythmia nor hypotensionnor hypotension

Abnormal ECG in 38%, Abnormal ECG in 38%, 27% stress test, 37% echo, 52% angio27% stress test, 37% echo, 52% angio 6 month outcome:6 month outcome:

– 23% readmission23% readmission– 12% revascularized12% revascularized– 3% deaths3% deaths

““Low-risk” is not no riskLow-risk” is not no risk

Devlin et al.et al.Eur Heart J 2001;22(Abstr Suppl):525.Eur Heart J 2001;22(Abstr Suppl):525.

Total Population = 9,980Total Population = 9,980

Evidence Based MedicineEvidence Based Medicine

ST ST MI MI Non- ST Non- ST MI MI UAUA % of % of pts pts who who are are

TherapyTherapy (n=2,501)(n=2,501) (n=2,504)(n=2,504) (n=3,631)(n=3,631) eligibleeligible

ASAASA XX XX XX

B blockerB blocker XX XX

ACE-IACE-I XX XX

ReperfusionReperfusion XX

GP IIb/IIIa/LMWHGP IIb/IIIa/LMWH XX XXGranger CB et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):503A. 2001;37(2 Suppl A):503A.

GRACE: Use of EBM in GRACE: Use of EBM in “Eligible” Patients“Eligible” Patients

93%

81%

64%70%

58%

71%

57%

89%

0%

20%

40%

60%

80%

100%

ASA B-blocker ACE-I Reperf LMWH/IIb/IIIa

% I

deal

Use

In-hosp

Discharge

14% PTCA

56% lytics

14% IIb/IIIa

48% LMWH

n=5,373 n=4,480 n=3,254 n=1,963 n=4112

Granger CB et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):503A. 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:Geographic Practice Variation:Discharge MedicationDischarge Medication

4753

94

4957

93

5450

94

53

26

93

0

20

40

60

80

100

ACE Statin AT/AC

Pat

ien

ts (

%)

United States

Australia/New Zealand/Canada

Europe

Argentina/Brazil

**P<0.01

AT/AC, antithrombin or anticoagulantFox KAA et al. Eur Heart J 2002;23:1177-89et al. Eur Heart J 2002;23:1177-89..

n=3420 of 8213 with CK, CK-MB

& troponin measurements

26

15

9

0

5

10

15

20

25

30

Troponin + in additionto CK ULN

Troponin + in additionto CK 2 x ULN

Troponin + in additionto CK-MB ULN

% In

cre

as

e in

Pa

tie

nts

w

ith

MI

Increase in Diagnosis of MI Increase in Diagnosis of MI Utilizing TroponinUtilizing Troponin

Goodman SG et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):358A 2001;37(2 Suppl A):358A..

In-Hospital MortalityIn-Hospital Mortality

5.8

32.1

0

2

4

6

8

CK 2 x ULNTroponin–

CK 2 x ULNTroponin +

CK > 2 x ULNTroponin–

CK > 2 x ULNTroponin +

Od

ds

Ra

tio

(1.6 - 5.7)

(0.6 - 7.4)

(3.3 - 10.1)

*

OR & 95% CI

*p<0.05

n=900n=900n=124n=124

*

Goodman SG et al. et al. J Am Coll CardiolJ Am Coll Cardiol 2001;37(2 Suppl A):358A 2001;37(2 Suppl A):358A ..

n=1111n=1111

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

77.8

18.1

74.5

18.5

70.3

18.3

69.5

25.4

0

20

40

60

80

100

Hx of CAD (n=4974) No Hx of CAD (n=6414)

Prior long-ASA use according to geographic region and history

Per

cen

tag

e

Australia/New Zealand/CanadaEurope

South AmericaUSA

Impact of Prior ASA on ACS: Impact of Prior ASA on ACS: GRACEGRACE

Type of ACS and Hospital Type of ACS and Hospital Mortality in Patients with History Mortality in Patients with History of CAD Stratified By Prior ASAof CAD Stratified By Prior ASA

Impact of Impact of prior ASA on:prior ASA on:– STEMI 0.52 STEMI 0.52

(0.44,0.61)*(0.44,0.61)*– Death 0.69 Death 0.69

(0.5,0.95)**(0.5,0.95)**15

28

58

3

26 29

45

7

0

20

40

60

80

STEMI NSTEMI UA Death

Prior ASA No prior ASA

*Controlled for age, sex, medical hx, prior therapies, in hospital therapies

**Controlled for above plus MI type

Type of ACS and Hospital Mortality Type of ACS and Hospital Mortality in Patients without History of CAD in Patients without History of CAD Stratified By Prior ASAStratified By Prior ASA

Impact of prior Impact of prior ASA on:ASA on:– STEMI 0.35 STEMI 0.35

(0.30,0.40)*(0.30,0.40)*– Death 0.77 Death 0.77

(0.55,1.07)**(0.55,1.07)**

25

31

44

5

51

2723

6

0

20

40

60

STEMI NSTEMI UA Death

Prior ASA No prior ASA

*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

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Prior Statins No Prior Statins

Hospital Statins No Hospital Statins

Pa

tient

sPrior and Early Utilization of Statins Prior and Early Utilization of Statins in Patients with ACS: GRACEin Patients with ACS: GRACE

Ann. Intern Med. 2004;140:856-866.Ann. Intern Med. 2004;140:856-866.

Final Diagnosis of ACS Patients Final Diagnosis of ACS Patients According to Previous Treatment According to Previous Treatment with Statinswith Statins

0

20

40

60

80

100

Previous Statin Use No Previous Statin Use

Pa

tie

nts

, %

St elevation MI* non-ST elevation MI Unstable angina

*Multivariate analysis: Prior statin users less likely to present with STEMI -OR 0.79 (0.71,0.88)


Hospital Outcomes of ACS Hospital Outcomes of ACS Patients Stratified by Statin UsePatients Stratified by Statin Use

Outcome Prior statins Prior & Hospital Hospital Statins Only Statin 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


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 Adjusted ORs for Hospital Events in Patients with ACS and Events in Patients with ACS and New-Onset Atrial FibrillationNew-Onset Atrial Fibrillation

0 0.5 1 1.5 2 2.5 3 3.5 4

Odds Ratio

Major bleed

Stroke

Cardiac arrest

Pulmonary edema

Shock

Death

AF Better AF Worse

Am J Cardiol 2003;92(9):1031-6

Adjusted ORs for Hospital Events in Patients with ACS and Previous Atrial Fibrillation

0 0.5 1 1.5 2 2.5

Odds Ratio

Major bleed

Stroke

Cardiac arrest

Pulmonary edema

Shock

Death

AF Better AF Worse

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 Impact of Heart Failure on Admission on Hospital MortalityAdmission on Hospital Mortality

1 10 20

>75 years

65-74 years

55-64 years

<55 years

3.1 (2.4,3.9)

3.3 (2.3,4.8)

5.0 (2.9,8.3)

10.1 (5.3,19.2)

Lower oddsratio for death Higher odds of death

*Relative to patients without HF

Circulation 2004;109:494-499.Circulation 2004;109:494-499.

Death Rates from Hospital Admission Death Rates from Hospital Admission to 6-Month Follow-Up for Patients to 6-Month Follow-Up for Patients According to Timing of Heart FailureAccording to Timing of Heart Failure

Circulation 2004;109:494-499. Circulation 2004;109:494-499.

Hospital Case-Fatality Rates Hospital Case-Fatality Rates According to Development of According to Development of Heart FailureHeart Failure

Group HF (+) HF (-)

All patients 12.0% 2.9%

STEMI 16.5% 4.1%

Non-STEMI 10.3% 3.0%

Unstable angina 6.7% 1.6%

Circulation 2004;109:494-499. 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 Probability of Survival at 6 Months (all PCI)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.et al.Catheter Cardiovasc Interv 2003;60:360-7.

Probability of Survival at Probability of Survival at 6 Months (Primary PCI)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.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*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

Gooldberg RJ et al.Am J Cardiol 2004;93:288-93.et al.Am J Cardiol 2004;93:288-93.

16.2

9.3

5.0

14.7

8.07.1

15.7

8.3

6.1

0

5

10

15

20

Cardiac cath PCI CABG

Pat

ien

ts (

%)

STEMI (5,476)

NSTEMI (5,209)UA (6,149)

Discharge to 6 Month Outcomes: Discharge to 6 Month Outcomes: Cardiac InterventionsCardiac Interventions

Scheduled and unscheduled procedures


6 Month Follow-up6 Month Follow-up

5.8

12.2

19.7

6.47.8

18.5

4.1

23.1

27.6

5.7

18.1 19.0

0

5

10

15

20

25

30

Death MI Rehosp

Pat

ien

ts (

%)

UFHLMWH

UFH + IIb/IIIaLMWH + IIb/IIIa


12

3

17

13

3

20

8

1.5

20

0

10

20

30

Death Stroke Urgentreadmission forcardiac event

Pa

tie

nts

(%

)

STEMI (2075)

NSTEMI (1856)

UA (2883)

Total Outcomes: Total Outcomes: Admission to 6 MonthsAdmission to 6 Months

50

60

70

80

90

100

0 1 2 3 4 5 6

Months after hospital discharge

% S

urv

ivin

g

STEMI Non-STEMI UA

Survival Rate 6 Months Post Survival Rate 6 Months Post Discharge for STEMI, NSTEMI, Discharge for STEMI, NSTEMI, and UA Patientsand UA Patients


Factors Associated With An Factors Associated With An Increased Risk of Post-Discharge Increased Risk of Post-Discharge DeathDeath

Characteristic STEMI Non-STEMIAge (yrs) HR 95% CI HR 95% CI 65-74 3.48 2.00-6.06 2.17 1.27-3.72 >75 8.95 5.28-15.20 5.30 3.19-8.80

Medical history HF 2.21 1.61-3.04 2.20 1.71-2.84 MI 1.69 1.28-2.22 TIA/Stroke 1.37 1.03-1.84

Hospital complications Cardiogenic shock 1.94 1.20-3.15 HF 2.16 1.65-2.83 1.91 1.49-2.44 Stroke 2.51 1.32-4.78


Factors Associated with an Factors Associated with an Increased Risk of Post-Discharge Increased Risk of Post-Discharge Death in Patients with UADeath in Patients with UA

CharacteristicAge (yrs) HR 95% CI 55-64 3.34 1.81-6.19 65-74 5.29 2.88-9.72

Medical history HF 2.23 1.61-3.08 MI 1.44 1.09-1.91 PCI 0.52 0.35-0.77 Hospital complications Cardiogenic shock 4.01 1.73-9.28 HF 1.67 1.17-2.37


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 Temporal Trends in ACS Diagnostic CategoriesACS Diagnostic Categories

0%

10%

20%

30%

40%

50%

1999(n=5513)

2000(n=8787)

2001(n=8934)

2002(n=8944)

2003 (n=5924)

Year of Discharge

Pat

ien

ts (

%)

STEMI Non-STE MI UA

Temporal Trends STEMI: Temporal Trends STEMI: In-hospital TherapiesIn-hospital Therapies

Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24. *without PCI*without PCI

0

20

40

60

Jul-Dec1999

Jan-Jul2000

Jul-Dec2000

Jan-Jul2001

Jul-Dec2001

Year of Treatment

Pat

ien

ts (

%)

LMWH Ticl/Clop GPIIb/IIIa*

0

20

40

60

Jul-Dec1999

Jan-Jul2000

Jul-Dec2000

Jan-Jul2001

Jul-Dec2001

Year of Treatment

Pat

ien

ts (

%)

Lytics Primary PCI* No reperfusion

Temporal Trends STEMI: Temporal Trends STEMI: ReperfusionReperfusion

Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24. *within 12 h*within 12 h

0

20

40

60

80

Jul-Dec1999

Jan-Jul2000

Jul-Dec2000

Jan-Jul2001

Jul-Dec2001

Year of Treatment

Pat

ien

ts (

%)

LMWH Ticl/Clop GPIIb/IIIa

Temporal Trends NSTEMI:Temporal Trends NSTEMI:In-hospital TherapiesIn-hospital Therapies

Fox KAA et al. Eur Heart J 2003;24:1414-24.Fox KAA et al. Eur Heart J 2003;24:1414-24.

GRACE Palm Pilot SoftwareGRACE Palm Pilot SoftwareIn-hospital, 6-monthsIn-hospital, 6-months

Death, Death/MI Prediction ModelDeath, Death/MI Prediction Model

GRACE PDA SoftwareGRACE PDA Software

At Admission Risk ModelAt Admission Risk Model

At Discharge Risk Model At Discharge Risk Model

GRACE PublicationsGRACE Publications

Abstract Acceptance Rate Abstract Acceptance Rate (1999 to 2007)(1999 to 2007)

81%

52%

41%

0%

20%

40%

60%

80%

100%

ESC ACC AHA

Acc

epte

d (

%)

Number of abstracts accepted = 111

Manuscript StatusManuscript Status

16

8

7

12

66

0 20 40 60 80

Unprioritized

Top priorityindependent

Edit/write assistance

Submitted/beingrevised

Published/in press

GRACE Quarterly Reports to GRACE Quarterly Reports to InvestigatorsInvestigators

Quarterly ReportQuarterly ReportCurrent Quarter vs. OverallCurrent Quarter vs. Overall

Quarterly ReportQuarterly ReportTemporal TrendsTemporal Trends

Unique Features of GRACEUnique Features of GRACE

Multi-national perspectiveMulti-national perspective Full spectrum of coronary syndromesFull spectrum of coronary syndromes Increased data on demographics, Increased data on demographics,

presentation, management and outcomepresentation, management and outcome Regular audits of data qualityRegular audits of data quality Feedback to participating sitesFeedback to participating sites 6-month follow-up6-month follow-up

global registry of acute coronary events assessing todays practice patterns to enhance tomorrows...

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