Trends in outcomes among older patients with non–ST-segment elevation myocardial infarction Chee Tang Chin, MBChB, MRCP(UK), a,b Tracy Y. Wang, MD, MHS, MSc, a Anita Y. Chen, MS, a Robin Mathews, MD, a Karen P. Alexander, MD, a Matthew T. Roe, MD, MHS, a and Eric D. Peterson, MD, MPH a Durham, NC; and Singapore Objectives The objective of this study is to assess trends in evidence-based therapy use and short- and long-term mortality over time among older patients with non–ST-segment elevation myocardial infarction (NSTEMI). Background With the prevalence of national quality improvement efforts, the use of evidence-based therapies has improved over time among patients with NSTEMI, yet it is unclear whether these improvements have been associated with significant change in short- and long-term mortality for older patients. Methods We linked detailed clinical data for 28,603 NSTEMI patients aged ≥65 years at 171 hospitals in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry with longitudinal Centers for Medicare & Medicaid claims data and compared trends in annual unadjusted and risk-adjusted inhospital and long-term mortality from 2003 to 2006. Results The median age of our NSTEMI study population was 77 years, 48% were female, and 87% were white. Overall, inhospital and 1-year mortality rates were 6.0% and 24.5%, respectively. When compared with patients treated in 2003, NSTEMI patients treated in 2006 were more likely to receive guideline-recommended inhospital medications and early invasive treatment. Inhospital mortality decreased significantly over the study period (5.5% vs 7.2% [adjusted odds ratio 0.82, 95% CI 0.67-1.00, P = .045] for 2006 vs 2003), but there was no significant change in 1-year mortality from the index admission (24.0% vs 26.0% [adjusted hazard ratio 0.99, 95% CI 0.90-1.08] for 2006 vs 2003). Conclusions Between 2003 and 2006, there was a significant reduction in inhospital mortality that corresponded to an increase in the use of evidence-based NSTEMI care. Nevertheless, long-term outcomes have not changed over time, suggesting a need for improved care transition and longitudinal secondary prevention. (Am Heart J 2014;167:36-42.e1.) Robust clinical trials have helped to optimize the management of patients with non–ST-segment myocardial infarction (NSTEMI). Findings from these trials have been summarized into evidence-based guidelines and recom- mendations. 1-4 Although previous studies have demon- strated gaps in the application of guidelines to the pharmacologic and invasive management of NSTEMI patients (particularly elderly patients), these guideline applications are improving via national quality improve- ment programs. 5-7 The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiol- ogy/American Heart Association Guidelines (CRUSADE) initiative was 1 such program associated with significant improvements in the adoption of evidence-based recom- mendations among participating hospitals. 8-10 Neverthe- less, the extent to which better acute evidence-based NSTEMI treatments may be associated with improved longitudinal outcomes following discharge is unknown. Our aims for this study were to describe annual trends in guideline-recommended treatment adherence, inhos- pital mortality, and 1-year mortality from the index admission among NSTEMI patients ≥65 years of age in the CRUSADE Registry. Methods Details of the CRUSADE Registry have been previously described. 8 Briefly, patients with acute coronary syndrome, including NSTEMI, were enrolled in CRUSADE if they had ischemic chest pain lasting ≥10 minutes within the preceding 24 hours, with either elevated local laboratory cardiac biomarker levels (either troponin or creatine kinase-MB, thus From the a Duke Clinical Research Institute, Durham, NC, and b National Heart Centre Singapore, Singapore. Submitted July 3, 2013; accepted October 12, 2013. Reprint requests: Chee Tang Chin, MBChB, MRCP(UK), National Heart Centre Singapore, 17 Third Hospital Ave, Singapore 168752. E-mail: chin.chee.tang@nhcs.com.sg 0002-8703/$ - see front matter © 2014, Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.ahj.2013.10.008