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Creating a Safer System 24-month national Campaign. For re-evaluation March 2007. To help teams develop skills/capacity to monitor their performance and make Quality Improvements (QI) Focus is harm reduction and improving care processes and outcomes for patients Canadian Adverse Events Study 7.5% of all hospital admissions are associated with an adverse event (2000) 36.9% of which were deemed preventable IE: 70,000 preventable adverse events per year Possibly contributing to 9,000 preventable deaths in Canada (2000) Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al (2004)) The Key focus of SHN: solving the implementation issues that stand between our knowledge of "what works” and our ability to reliably provide this standard of care Safer Healthcare Now! aims to provide quality improvement ideas, supports and resources to hospital teams with the goal of providing safer care. 160 healthcare organizations and 470 teams enrolled nationwide (68 teams in Atlantic Canada) Partners include CMA, CCHSA, DOH, Professional Colleges , Associations of Health Organizations Six Improvement Initiatives: – Acute Myocardial Infarction (AMI) – Medication Reconciliation – Surgical Site Infection (SSI) – Rapid Response (RRT) – Central Line Infection – Ventilator Associated Pneumonia (VAP) Cumulative 6-month mortality from ischemic heart disease Deaths / 100 pts / month 25 N = 21,761; 1985-1992 Diagnosis on adm to hosp 20 15 Acute MI Unstable angina Stable angina 10 5 0 0 1 2 3 4 Months after hospital admission Duke Cardiovascular Database 5 6 7 Atherosclerosis Timeline Foam Cells Complicated Lesion/ Fatty Intermediate Fibrous Rupture Streak Lesion Atheroma Plaque Endothelial Dysfunction From First Decade From Third Decade Adapted from Pepine CJ. Am J Cardiol. 1998;82(suppl 104). From Fourth Decade Plaque Rupture and Clot Formation 9 Acute Coronary Syndrome No ST Elevation ST Elevation NSTEMI Unstable Angina Myocardial Infarction NQMI Qwave MI Serum Cardiac Markers Dx: MI Prognosis Selection of Rx Dx: Reinfarction Prognosis 10 Assess Reperfusion Early Mortality After AMI % Mortality 25 Mortality at 25 - 30 Days 20 15 10 5 0 1967 1970 1979 Pre-CCU CCU b-Block 1986 1990 1993 1997 1999 GISSI-1 ISIS-2 GUSTO GUSTO-3 ASSENT-2 tPA & SK tPA & SK+ASA tPA rPA TNK 12 Definition of AMI Patients admitted through ER with diagnosis of AMI confirmed by 2 of : documented symptoms compatible with AMI ST elevation in 2 contiguous leads or new LBBB documented enzyme elevation. Ischemic chest pain 30 min 14 Ischemic chest pain 30 min Acute Anterior Injury 15 Ischemic Chest Pain – 30 min 16 Ischemic Chest Pain – 30 min Acute inferior injury 17 ST Elevation MI: Management Principles 1. Achieve early and complete reperfusion of the infarctrelated vessel a. Primary Percutaneous intervention (PCI) b. Thrombolytic therapy 2. Use evidence-based adjunctive medical therapy a. ASA b. Beta blockers c. Angiotensin converting enzyme(ACE) inhibitors d. Statins e. Antithrombotic therapy (when indicated) 18 Primary PCI vs. Thrombolysis PAMI TRIAL: 395 patients Events: Death, recurrent MI or ischemia requiring revascularization 53% event free survival 37 % event free survival From www.uptodate.com . Accessed on July 29, 2003 19 Fibrinolytic Therapy Is It A Treatment of the Past? • Meta-analysis of 23 randomized trials • Primary PCI reduced Death 7% vs 9% Reinfarction Stroke 2.5% vs 1% vs Lancet 2003; 361:13-20 6.8% 2% 20 Fibrinolysis vs. Transport for PCI • On-site (community hospital) fibrinolysis compared with immediate transport to a regional center for PCI for STEMI • A consistent 40% reduction in AE • Time delay for transport were 10, 30, 43 min (277 min Odds ratio and 95% confidence intervals for the composite end point of death, reinfarction, for PCI vs 245 min for and stroke at 30 days fibrinolysis) ACC Scientific Sessions; March 20, 2002: Atlanta, Ga ESC; September 1, 2002: Berlin, Germany J Am Coll Cardiol. 2002; 39: 1713–1719 21 Fibrinolytic Therapy Is It A Treatment of the Past? • Resistance to primary PCI – Not enough Primary PCI studies have been performed – Results may not be reproducible in low volume and less experienced centers – Withholding thrombolytic while awaiting PCI may cause harm 22 Benefits of PCI vs Lysis: The Importance of Timing Kent DM et al Eff Clin Pract 4: 214, 2001 Thrombolytic Therapy: Importance of Early Therapy Benefit Greatest within Two hours of therapy Benefit falls by 1.6 lives per 1000 patients per hour of treatment delay after two hours Data from Boersma,E et al. Lancet 1996;348: 771 24 ST Elevation MI: Importance of Early Reperfusion TIMI 0=Occlusion TIMI 1= Penetration TIMI 2= Slow Flow TIMI 3= Normal Flow 25 Thrombolytic Therapy: Ineligible Patients 26 From www.uptodate.com. Accessed July 28, 2003 ST elevation MI • Fibrinolysis – TNK (tPA, rPA, SK) then • Low molecular weight heparin (Enoxaparin) - 30 mg bolus IV under age 75 and - 1 mg/kg sq bid - Age 75 and up – 0.75 mg/kg sq bid. or • Unfractionated heparin for very obese over 145 kg, renal failure 27 Thrombolytic Therapy: Bottom Line • Earlier (within two hours of symptoms) administration associated with better outcomes but benefit shown up to 12 hours • Overall efficacy in achieving TIMI 3 flow is 50-60% • Risk of Hemmorragic Stroke Low (0.49%-0.72%) – Less with SK than with t-PA or TnK • 40% of patients are INELIGIBLE for thrombolytic therapy • Current Agent of Choice: Tenecteplase (TnK) • Primary PCI better: – Higher rate of TIMI 3 flow (>90%) – Negligible risk of Intracranial Hemmorrhage – Associated with improved outcomes 28 Summary - STEMI • ST-segment elevation ACS should receive reperfusion therapy (PCI or fibrinolysis) as a medical emergency • Early use of aspirin, b-blockers, ACE inhibitors (in LV dysfunction), antithrombin agents, antiplatelet therapies • Center with invasive facilities have better outcomes 29 Figure 6 TIMI Risk Score for STEMI Historical Age 65-74 75 DM/HTN or angina Exam SBP < 100 HR >100 Killip II-IV Weight < 67 kg 2 points 3 points 1 point 3 points 2 points 2 points 1 point Presentation Anterior STE or LBBB Time to rx > 4 hrs 1 point 1 point Risk Score = Total (0 -14) (FRONT) Risk Score 0 1 2 3 4 5 6 7 8 >8 Odds of death by 30D* 0.1 0.3 0.4 0.7 1.2 2.2 3.0 4.8 5.8 8.8 (0.1-0.2) (0.2-0.3) (0.3-0.5) (0.6-0.9) (1.0-1.5) (1.9-2.6) (2.5-3.6) (3.8-6.1) (4.2-7.8) (6.3-12) *referenced to average mortality (95% confidence intervals) (BACK) TIMI Risk Score for STEMI Palm Pilot application available at: www.timi.org 31 From www.uptodate.com. Accessed June 28, 2003 WMH AMI Committee Julie SuttonTeam Leader Dr. Jamie GrahamCardiac Physician Rep. Bonnie WalkerPatient Safety Rep. Dr. Peter CallahanER Physician Rep. Maureen DoodyEducator Rep. Brenda RexICU Rep. Suzanne Joseph 3A Manager Rep. Rhonda Squires3A PCC Rep. AMI Statistics Prompt ASA reduces risk of death by 15% ; Beta-blockers reduce risk of death in first week by 13% and long term mortality by 23% RAND study (NEJM) showed only 61% of AMI patients receive ASA and only 45% receive beta-blockers AMI Key Components 1. Early administration of aspirin (within 24 hours) 2. Timely thrombolytic (within 30 minutes) 3. Aspirin at discharge 4. Beta-blocker at discharge 5. ACE-inhibitor at discharge (if systolic dysfunction) 6. Smoking cessation counseling Potential Cumulative Impact of 4 Simple Secondary Prevention Treatments "Yusuf S., Unpublished data." RRR None Event rate 8% ASA 25% 6% b-Blockers 25% 4.5% Lipid lowering 30% 3.0% ACE-inhibitors 25% 2.3% CUMULATIVE BENEFITS ARE LIKELY TO BE IN EXCESS OF 35 75% RRR, WHICH IS SUBSTANTIAL AMI Baseline Data BASED on Retrospective Chart Review March -September 2005 74 Charts Identified, 20 Excluded 54 reviewed for compliance and documentation with each of AMI components and overall (Perfect Care) AMI Baseline Data vs. Goals 100.0% 90.0% % of Patients Receiving Intervention 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Baseline Goal Aspirin at Arrival Thrombolytic Admin < 30 min Aspirin at Discharge Beta Blocker at Discharge ACE or ARB at Discharge Smoking Cessation "Perfect Care" 91.0% 80.0% 92.5% 90.0% 70.0% 50% 41.0% 90% 85% 90% 90% 85% 100% 95% Acute MI: ASA benefit ISIS-2: 17, 187 patients: Acute MI 23% mortality reduction 42% mortality reduction 38 1. Early Administration of ASA Goal: >90% compliance Aspirin 24 hrs before or after hospitalization Exclusions: Documented contraindications: (ASA allergy, active bleeding, warfarin before arrival) Transferred in from or out to another acute care facility ASA on Arrival 100 90 80 WMRH Atlantic Canada 70 60 50 2005 Mar-06 Jun-06 40 Thrombolysis: Decay with Delay 100 80 Percent Benefit 60 40 20 0 0 2 4 6 Hours Delay 8 10 12 41 2. Timely Thrombolysis Goal: >85% compliance Thrombolytic Agent within 30 minutes (door to needle)of arrival Exclusions: Transferred in from another facility No ST elevation or new LBBB present Did not receive a thrombolytic or received thrombolytic more than 6 hrs after arrival Thrombolytic within 30 min 100 90 80 70 60 50 40 30 20 10 0 WMRH Atlantic Canada 2005 Mar-06 Jun-06 43 Aspirin Evidence: Secondary Prevention Effect of antiplatelet therapy* on vascular events** Category % Odds Reduction Acute myocardial infarction Acute stroke Prior myocardial infarction Prior stroke/transient ischemic attack Other high risk Coronary artery disease (e.g. unstable angina, heart failure) Peripheral arterial disease (e.g. intermittent claudication) High risk of embolism (e.g. atrial fibrillation) Other (e.g. diabetes mellitus) All trials 0.0 0.5 1.0 1.5 2.0 Antiplatelet better Control better *Aspirin was the predominant antiplatelet agent studied **Vascular events include MI, stroke, or death Antithrombotic Trialist Collaboration. BMJ 2002;324:71–86. 44 Aspirin Evidence: Dose and Efficacy Indirect Comparisons of Aspirin Doses on Vascular Events in High-Risk Patients Aspirin Dose No. of Trials (%) 500-1500 mg 34 19 160-325 mg 19 26 75-150 mg 12 32 <75 mg 3 13 Any aspirin 65 23 0 Odds Ratio for Vascular Events P<.0001 0.5 Antiplatelet Better 1.0 1.5 2.0 Antiplatelet Worse 45 Antithrombotic Trialists Collaboration. BMJ. 2002;324:71-86 3. Discharged on ASA Goal: >90% compliance Aspirin prescribed on discharge Exclusions: Documented contraindications: (ASA allergy,active bleeding, warfarin before arrival) Transferred out to another acute care facility ASA at Discharge 100 95 90 WMRH Atlantic Canada 85 80 75 70 2005 Mar-06 Jun-06 47 Acute MI: Benefit of Beta Blockers 201, 752 patients with MI Mortality reduction: 14.4% vs. 23.9% at 2 years 48 Data from Gottlieb, SS et al. NEJM 1998;339:489 b-blocker Evidence Summary of Secondary Prevention Trials of b-blocker Therapy Phase of Treatment Total # Patients RR (95% CI) Acute treatment 28,970 0.87 (0.77-0.98) Secondary prevention 24,298 0.77 (0.70-0.84) Overall 53,268 0.81 (0.75-0.87) 0.5 CI=Confidence interval, RR=Relative risk 1.0 RR of death b-blocker Placebo better better 2.0 Antman E, Braunwald E. Acute Myocardial Infarction. In: Braunwald E, Zipes DP, Libby P, eds. Heart 49 Disease: A textbook of Cardiovascular Medicine, 6th ed., Philadelphia, PA: W.B. Sanders, 2001, 1168. b-blocker Evidence: Post MI with Left Ventricular Dysfunction Carvedilol Post-Infarct Survival Control in LV Dysfunction (CAPRICORN) Proportion Event-free 6,644 patients with LVEF <0.40 after a MI with or without HF randomized to carvedilol or placebo for 24 months 1 0.95 n=975 0.9 Carvedilol n=984 0.85 0.8 0.75 0.7 RR 0.77 P=.03 0 0.5 1 1.5 Placebo 2 2.5 Years 50 The CAPRICORN Investigators. Lancet. 2001;357:1385–1390. 4. Discharged on Beta Blocker Goal: >90% compliance Beta Blocker prescribed on discharge Exclusions: Documented contraindications: (allergy, bradycardia or BP < 90 systolic day of or day prior to discharge when not on beta blocker, 2nd/3rd degree HB without a pacemaker,) Transferred out to another acute care facility Beta Blocker at Discharge 100 95 90 WMRH Atlantic Canada 85 80 75 70 2005 Mar-06 Jun-06 52 Acute MI: ACE Inhibitor Benefit Data from Pfeffer, MA et al.NEJM 1992;327: 669 53 ACE Inhibitor Evidence: Post MI with LVD or HF AIRE SAVE Probability of Event Radionuclide EF 40% 0.4 TRACE Clinical and/or radiographic signs of HF Echocardiogram EF 35% Placebo 0.35 ACE-I 0.3 0.25 0.2 0.15 0.1 OR: 0.74 (0.66–0.83) 0.05 0 0 1 2 3 4 Years ACE-I=Angiotensin converting enzyme inhibitors, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction, OR=Odds ratio 54 Flather MD, et al. Lancet. 2000;355:1575–1581 % Death, MI, or Stroke HOPE Primary Results Benefits of ACE Inhibitors 0.2 Ramipril Placebo 0.15 0.1 0.05 p<0.001 0 0 500 1000 1500 Days of Follow-up 55 ACE Inhibitor Evidence: Secondary Prevention Comparison between the HOPE and PEACE trials 20 HOPE, placebo MI, Cardiac death, or Stroke (%) HOPE, active drug (ramipril) PEACE, placebo 15 10 5 0 0 1 2 3 4 5 Years *Reflects greater blood pressure control, revascularization, and use of other risk-reducing medications (i.e., antiplatelet therapy, b-blocker, lipid-lowering medication) CHD=Coronary heart disease, MI=Myocardial infarction Braunwald, E. et al., NEJM 2004;351:2058-68. 56 ARB Evidence: Heart Failure Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity (CHARM) Alternative Trial 2,028 patients with symptomatic HF, LVSD (EF <40%), and intolerance to ACE-I randomized to candesartan (32 mg) or placebo over 34 months CV Death of Hospitalization for HF 50 Placebo 40 Candesartan 30 20 10 HR 0.77 p=0.0004 0 0 1 2 Years 3 ACE-I=Angiotensin converting enzyme inhibitors, ARB=Angiotensin receptor blockers, EF=Ejection fraction, HF=Heart failure, LVSD=Left ventricular systolic dysfunction Granger CB et al. Lancet. 2003;362:772-777 57 ARB Evidence: Post MI with LVD or HF Valsartan in Acute Myocardial Infarction Trial (VALIANT) All Cause Mortality 14,703 patients with post-MI HF or LVSD (EF <0.40) randomized to captopril (50 mg three times daily), valsartan (160 mg twice daily), or captopril (50 mg three times daily) plus valsartan (80 mg twice daily) over 2 years 0.4 Captopril 0.3 Valsartan Valsartan and Captopril 0.2 0.1 Valsartan vs. Captopril: HR = 1.00; P = 0.982 Valsartan + Captopril vs. Captopril: HR = 0.98; P = 0.726 0.0 0 6 12 18 24 30 36 Months EF=Ejection fraction, HR=Hazard ratio, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction, RAS=Renin angiotensin system 58 Pfeffer M et al. NEJM 2003;349:1893-1906. 5. Discharged on ACEI/ARB Goal: >85% compliance ACE Inhibitor prescribed on discharge Exclusions: Documented contraindication: (allergy/intolerance, moderate to severe aortic stenosis, renal dysfunction, systolic BP <100mmHg, K+ > 4.5) Transferred out to another acute care facility ACEI/ARB at Discharge 100 90 80 WMRH Atlantic Canada 70 60 50 40 2005 Mar-06 Jun-06 60 Cigarette Smoking Cessation: Risk of Non-fatal MI* RR (95% Cl) Study Aberg, et al. 1983 0.67 (0.53-0.84) Herlitz, et al. 1995 0.99 (0.42-2.33) Johansson, et al. 1985 0.79 Perkins, et al. 1985 3.87 (0.81-18.37) Sato, et al. 1992 0.10 (0.00-1.95) Sparrow, et al. 1978 0.76 (0.37-1.58) Vlietstra, et al. 1986 0.63 (0.51-0.78) Voors, et al. 1996 0.54 (0.29-1.01) 0.1 Ceased smoking *Includes those with known coronary heart disease Critchley JA et al. JAMA. 2003;290:86-97. 1.0 Continued smoking (0.46-1.37) 10 CI=Confidence interval, RR=Relative risk 61 6. Smoking Cessation Counseling on Discharge Goal: 100 % compliance Received smoking cessation advice,counselling and/or pharmocological therapy or referral to Cardiac Rehab during hospitalization Exclusions: No history of smoking cigarettes, cigars or pipe anytime in year prior to admission Transferred out to another acute care facility Smoking Cessation Advice 90 80 70 60 50 WMRH Atlantic Canada 40 30 20 10 0 2005 Mar-06 Jun-06 63 7. “Perfect Care” for AMI Goal 95%compliance The percentage of AMI patients who received all 6 evidence based elements. documentation of all 6 elements of care in appropriate time frames, documentation of clearly defined contraindications . “Perfect Care” 100 90 80 70 60 50 40 30 20 10 0 WMRH Atlantic Canada 2005 Mar-06 Jun-06 65 Acute MI: Statin Benefit 20, 536 patients in Heart Protection Study 66 Data from: Heart Protection Study. Lancet 2002;360:7 HMG-CoA Reductase Inhibitor: Secondary Prevention Relationship between LDL Levels and Event Rates in Secondary Prevention Trials of Patients with Stable CHD 30 4S Statin Placebo Event (%) 25 4S 20 LIPID 15 LIPID CARE 10 HPS 5 0 CARE HPS TNT (atorvastatin 10 mg/d) TNT (atorvastatin 80 mg/d) 0 70 90 110 130 150 LDL-C (mg/dL) 170 190 210 LDL-C=Low density lipoprotein cholesterol; TNT=Treating to New Targets; HPS=Heart Protection Study; CARE=Cholesterol and Recurrent Events Trial; LIPID=Long-term Intervention with Pravastatin in Ischaemic Disease; 4S=Scandinavian Simvastatin Survival Study. 67 LaRosa JC et al. NEJM. 2005;352:1425-1435 Statin at Discharge 100 90 80 70 WMRH 60 50 40 Mar-May 06 June-July 06 68 Improvement Model PDSA What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Act Plan Study Do Plan a test Try it Observe the results Act on what is learned Act Plan Study Do make changes Test again make changes a e Test again make changes Test Smoking Rehab c h a n g e s Improvements in Progress Combining 2 Routine MI order sheets STEMI / NSTEMI to one Reviewing Thrombolytic Standing Order sheet Reviewing Nicotine Replacement addition to hospital formulary Next Steps: Concurrent Data Uses tests of change that allow changes while patient still in hospital Allows identification of missed interventions so they can be corrected before the patient is discharged Results in improved AMI care for patients MI Work sheet 74 Contraindications – p.2 75 Frontline Staff Can Make a Difference! MD’s: please use MI order sheet Checklist of interventions for improved care for AMI into care processes During hospitalization check for interventions and document each as completed or contraindicated Components of Secondary Prevention Cigarette smoking cessation Blood pressure control Lipid management to goal Physical activity Weight management to goal Diabetes management to goal Antiplatelet agents / anticoagulants Renin angiotensin aldosterone system blockers Beta blockers Influenza vaccination 77 Blood Pressure: Lower is Better Age at Risk (Y) 80-89 256 128 70-79 64 60-69 32 50-59 16 40-49 8 4 2 1 0 Ischemic Heart Disease Mortality Ischemic Heart Disease Mortality Ischemic Heart Disease Mortality 256 Age at Risk (Y) 80-89 128 70-79 64 60-69 32 50-59 16 40-49 8 4 2 1 0 120 140 160 180 Usual Systolic BP (mm Hg) BP=Blood pressure Prospective Studies Collaboration. Lancet. 2002;360:1903-1913 70 80 90 100 110 Usual Diastolic BP (mm Hg) 78 Exercise Evidence: Mortality Risk Observational study of self-reported physical activity in 772 men with established coronary heart disease Light or moderate exercise is associated with lower risk Wannamethee SG et al. Circulation 2000;102:1358-1363 79 CV Risk Increases with Body Mass Index Hazard Ratio Hemorrhagic Stroke Ischemic Stroke Ischemic Heart Disease 4.0 4.0 4.0 2.0 2.0 2.0 1.0 1.0 1.0 0.5 0.5 0.5 16 20 24 28 32 36 16 20 24 28 32 36 16 20 24 28 32 36 Body Mass Index (kg/m2)* CV=Cardiovascular Body mass index is calculated as the weight in kilograms divided by the body surface area in meters2. Mhurchu N et al. Int J Epidemiol 2004;33:751-758 80 Clopidogrel Evidence: ACS (Non-STEMI and UA) Clopidogrel in Unstable Angina to Prevent Recurrent Events (CURE) Trial Rate of death, myocardial infarction, or stroke 12,562 patients with a NSTEMI-ACS randomized to daily aspirin (75-325 mg) or clopidogrel (300 mg load, 75 mg thereafter) plus aspirin (75325 mg) for 3-12 months (average 9 months) 0.14 Aspirin + Clopidogrel Aspirin + Placebo 0.12 0.10 0.08 0.06 0.04 0.02 P<0.001 0.00 0 3 6 9 12 Months of Follow Up NSTEMI-ACS=Non ST-segment elevation acute coronary syndrome 81 The CURE Trial Investigators. NEJM. 2001;345:494-502 Aldosterone Antagonist: Heart Failure Randomized Aldactone Evaluation Study (RALES) 1,663 patients with NYHA Class III or IV HF and LVSD (EF <0.35) randomized to spironolactone (25 mg) or placebo (50 mg) for 24 months Survival (%) 1.00 Spironolactone Placebo .90 .80 .70 .60 .50 RR = 0.70, P<0.001 0 0 3 6 9 12 15 18 21 24 27 30 33 36 Months EF=Ejection fraction, HF=Heart failure, LVSD=Left ventricular systolic dysfunction, NYHA=New York Heart Association Pitt B et al. NEJM 1999;341:709-717 82 Aldosterone Antagonist: Post MI HF and LVSD Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) All Cause Mortality (%) 6,644 patients with evidence of heart failure and LVSD (EF <0.40) after a MI randomized to eplerenone (50 mg) or placebo for 16 months Eplerenone Placebo 25 20 15 10 5 0 RR = 0.85, P=0.008 0 6 12 18 24 30 36 Month EF=Ejection fraction, LVSD=Left ventricular systolic dysfunction, MI=Myocardial infarction Pitt B et al. NEJM 2003;348:1309-21 83 Impact of AHA Get With The Guidelines-CAD Program on Quality of Care Baseline * 100 90 80 70 60 50 40 30 20 10 0 * * 97 9796 95 93 Q1 Q2 8787 * 64656567 Aspirin Q4 * p< 0.05 compared to baseline * * * 91 83 79 Q3 68 Beta Blocker ACE Inhibitor GWTG-CAD: 123 US Hospitals n=27,825 Labresh, Fonarow et al. Circulation 2003;108:IV-722 * * * 75 73 6770 74 * * * 82 * 7675 70 57 Lipid Rx Smoking Cessation 84 Questions ?