Safer Antithrombotic Therapy for Elderly ACS Patients

描述(申请人提供)：非ST段抬高急性冠脉综合征(NSTE ACS)是老年人的一种常见和致命的疾病。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，部分原因是他们相关的出血风险。重要的是，我们有新的证据表明，这些风险很可能通过个性化的抗血栓药物剂量来改变。 在具体目标1中，我们建议使用美国最大的NSTE ACS注册中心CRUSADE的详细临床信息(拥有450多家现有医院和另外130多家退伍军人健康管理局(VHA)医院)来确定老年NSTE ACS患者的出血发生率以及这种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药物剂量指南的频率，这些规则在老年患者中的普适性，以及与过量剂量相关的后果。 然后，我们将进行一项多中心随机对照试验，以减少NSTE急性冠脉综合征出血事件(特定目标3)。我们质量改进干预的主要目标将是通过增加对抗血栓药物剂量指南的遵守来降低老年人的出血率。药物安全性的提高也应该增加老年NSTE ACS患者抗血栓药物的总体适当使用，并最终改善患者的预后。 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保持改进的业绩(具体目标4)。最后，我们将利用与专业协会和VHA建立的关系来广泛传播我们研究的主要发现。

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.