Safer Antithrombotic Therapy for Elderly ACS Patients

描述（由申请人提供）：非ST段抬高急性冠状动脉综合征（NSTE ACS）是老年人常见的致命疾病。急性抗血栓治疗是有效的，但在老年患者中未得到充分利用，部分原因是其相关的出血风险。重要的是，我们有新的证据表明，这些风险可能通过个体化抗血栓药物给药来改变。 在具体目标1中，我们建议使用来自CRUSADE的详细临床信息，CRUSADE是美国最大的NSTE ACS登记中心（现有450多家医院，另有130多家退伍军人健康管理局（VHA医院）），以确定老年NSTE ACS患者的出血发生率以及该风险的临床预测因素。 在特定目标2中，我们将确定与出血风险相关的特定可修改护理因素。我们将评估当前实践中超过抗血栓剂量指南的频率，这些规则在老年患者中的普遍性，以及与过量给药相关的后果。 然后，我们将进行一项多中心随机对照试验，以减少NSTE ACS出血事件（具体目标3）。我们质量改进干预的主要目标是通过增加对抗血栓剂量指南的依从性来降低老年人的出血率。提高药物安全性还应增加抗血栓药物在老年NSTE ACS患者中的总体适当使用，并最终改善患者结局。 我们还将严格评估与我们的质量改进干预措施成功相关的因素;并确定是否需要保持这种努力以维持改进的绩效（具体目标4）。最后，我们将利用与专业协会和VHA建立的关系，广泛传播我们研究的主要结果。

DESCRIPTION (provided by applicant): Non-ST elevation acute coronary syndrome (NSTE ACS) is a both common and mortal condition in the elderly. Acute antithrombotic therapy is efficacious, yet under-utilized in older patients due in part to their associated bleeding risks. Importantly, we have new evidence that these risks are likely modifiable via individualized antithrombotic drug dosing. In Specific Aim 1 we propose to use detailed clinical information from CRUSADE, the nation's largest NSTE ACS registry (with 450+ existing hospitals, and an additional 130+ Veterans Health Administration (VHA hospitals) to determine the incidence of bleeding in elderly NSTE ACS patients as well as the clinical predictors of this risk. In Specific Aim 2, we will determine specific modifiable care factors associated with bleeding risks. We will assess the frequency that antithrombotic dosing guidelines are exceeded in current practice, the generalizability of these rules in elderly patients, as well as the consequences associated with excessive dosing. We will then conduct a multicenter randomized control trial to reduce NSTE ACS bleeding events (Specific Aim 3). The primary goals of our quality improvement intervention will be to reduce bleeding rates in the elderly via increasing adherence to antithrombotic dosing guidelines. Improved drug safety should also increase the overall appropriate use of antithrombotic agents in elderly NSTE ACS patients, and ultimately, to improve patient outcomes. We also will critically evaluate factors associated with the success of our quality improvement intervention; and ascertain whether such efforts need to be maintained to sustain improved performance (Specific Aim 4). Finally, we will use established relations with professional societies and the VHA to widely disseminate our study's major findings.