Context: The American College of Cardiology/American Heart Association(ACC/AHA ) guidelines for the management of non-ST-segment elevation acute coronary syn dromes(NSTE ACS) recommend early invasive management for high-risk patients, gi ven the benefits with this approach demonstrated in randomized clinical trials. Objectives: To determine the use and predictors of early invasive management str ategies(cardiac catheterization <48 hours following presentation) in high-risk patients with NSTE ACS and to examine the association of early invasive management with mortality. Design, Set ting, and Patients: The CRUSADE(Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Gui delines) Quality Improvement Initiative evaluated care patterns and outcomes for 17926 high-risk NSTE ACS patients (positive cardiac markers and/or ischemie el ectrocardiographic changes) based on ACC/AHA guidelines recommendations at 248 U S hospitals with catheterization and revascularization facilities between March 2000 and September 2002. Main Outcome Measures: Use of early invasive management within 48 hours of presentation, predictors of early invasive management, and i n-hospital mortality. Results: Of the 17926 patients analyzed, 8037 (44.8%) un derwent early cardiac catheterization less than 48 hours following presentation. Predictors of early invasive management included cardiology care, younger age, lack of prior or current congestive heart failure, lack of renal insufficiency, ischemic electrocardiographic changes, positive cardiac markers, white race, and male sex. Patients treated with early invasive management were more likely to b e treated with medications and interventions recommended by the ACC/AHA guidelin es and had a lower risk of in-hospital mortality after adjusting for difference s in clinical characteristics and after comparing propensity-matched pairs (2.5 %vs 3.7%, P< .001). Conclusions: An early invasive management strategy is not utilized in the majority of high-risk patients with NSTE ACS. This strategy app ears to be reserved for patients without significant comorbidities and those car ed for by cardiologists and is associated with a lower risk of in-hospital mort ality.
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