Cardiologists from the University of North Carolina at Chapel Hill, the Duke Clinical Research Institute and other leading medical centers officially launched a 60,000-patient project aimed at encouraging physicians to follow published practice guidelines for high-risk acute cardiac patients.

The quality improvement initiative is named CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines). The project received data on its first patients in October and will include some 600 hospitals nationwide.

"During the next decade we are likely to see an overwhelming epidemic of coronary artery disease within the aging population. The appropriate use of the ACC/AHA recommended therapies is therefore even more important to further improve cardiovascular outcomes," said Dr. E. Magnus Ohman, Chief of Cardiology at the University of North Carolina School of Medicine and co-chairman of the CRUSADE Executive Committee. "The CRUSADE Initiative represents an important effort to help individual hospitals in the US improve the delivery of cardiovascular healthcare."

CRUSADE will analyze treatment patterns for up to 60,000 patients treated at hospitals for certain chest pain disorders known as unstable angina or Non-ST-segment Elevation Acute Coronary Syndromes (NSTE ACS). Aggregate data regarding the treatment, procedures, and medications received by patients with this diagnosis will be collected. The aggregated analyzed data from each hospital will then be reported back to the hospital for use in improving its own patient care. The hospital can then educate its physicians and staff on how to improve patient care according to accepted guidelines.

Each year, 1.3 million Americans are hospitalized due to unstable angina or, based on electrocardiogram testing, non-ST-segment elevation myocardial infarction. These disorders are collectively known as NSTE ACS and are serious heart conditions caused by partial blockage of blood supply to the heart muscle by a coronary thrombus, a clump of blood components known as platelets. Up to one in seven patients with this condition dies or has a heart attack within 30 days of hospitalization.

Last year, the American College of Cardiology and American Heart Association developed consensus guidelines for the care of patients with NSTE ACS. These guidelines emphasize the importance of early risk stratification beginning when a patient arrives in the emergency room. The guidelines also emphasize timely use of newer anti-platelet and anti-thrombotic therapies for those diagnosed as high-risk. However, despite the increasing emphasis on practicing evidence-based medicine, the ACC/AHA Guidelines have not been widely adopted in routine clinical practice.

"The development of ACC/AHA guidelines doesn't stop with their publication," stated Dr. Sidney C. Smith, Jr., professor of medicine at the University of North Carolina School of Medicine and Chief Science Officer of the American Heart Association. "The guidelines need to be broadly implemented. When physicians are aware of guidelines, chances are that they will follow them. That's why the American Heart Association has developed a secondary prevention guideline implementation program called Get With the Guidelines. Programs like Get With the Guidelines and CRUSADE will raise awareness among physicians and hospitals and should increase the use of guidelines. Patients will ultimately benefit."

The need for quality improvement efforts such as CRUSADE is supported by results from a survey conducted by the Duke Clinical Research Institute and administered to cardiologists, emergency medicine physicians, and nurses. These results suggest that many doctors do not always follow the ACC/AHA Guidelines; moreover, in many cases they are not even familiar with the guidelines. Those responding to the survey estimated that only 45 percent of cardiologists and 15 percent of emergency medicine physicians at their institution were familiar with the ACC/AHA Guidelines for NSTE ACS patient care.

"One of the biggest challenges facing the healthcare system in the US is to ensure the universal adoption of treatment guidelines established to optimize patient care," stated Dr. Robert M. Califf, director of the Duke Clinical Research Institute, which will help coordinate the CRUSADE project with the University of North Carolina at Chapel Hill and the University of Cincinnati. "Significant efforts are exerted to develop treatment guidelines based on the evidence from large-scale clinical trials and from clinical practice. Unfortunately, little effort is then placed on ensuring their adoption. Patient care, as a result, may be compromised."

The CRUSADE Quality Improvement Initiative is intended to address this problem by offering hospitals and healthcare professionals specific quality improvement initiatives and tools designed to promote adherence to the ACC/AHA Guidelines for high-risk patients with non-ST-elevation ACS, and to improve clinical outcomes with their early implementation.

The emphasis on early implementation-that is, treating patients according to the guidelines as soon as they arrive in the emergency room-necessitates cooperation between emergency physicians and the cardiologists responsible for patients' long-term care.