| BackgroundIt is well known that cardiovascular disease (CVD) especially coronary heart disease (CHD) has become the world's number one cause of death and disability in 21st century, which thanks largely to the transition of human disease profile and world economic development. In the United States, nearly 1.5 million patients suffered from NSTEACS annually. There were 950 thousand people died from CVD and CHD accounted for 70 percent in 1993. It has been reported by the American Heart Association (AHA) there was one cardiovascular death every 33 seconds in 1996. There is lower incidence of CHD in China and other developing countries compared with developed countries at present. However, CHD will become the number one killer of all deaths with the economic development and the changes of people's lifestyles.Acute coronary syndrome(ACS) includes unstable angina(UA), non-ST segment elevation myocardial infarction(NSTEMI), ST segment elevation myocardial infarction(STEMI), cardiogenic sudden death. At present,we discriminate ST segment elevation acute coronary syndrome(STEACS) and non-ST segment elevation acute coronary syndrome(NSTEACS) on the basis of whether ST segment elevate or not on the electrocardiogram(ECG).NSTEACS includes UA and NSTEMI,STEACS is mainly STEMI. As a kind of CHD, NSTEACS has attracted more and more attention and clinical and epidemiological studies in this domain flourished greatly. Since 1990, guidelines on the management of patients with NSTEACS, congestive heart failure (CHF), hypertension or hyperlipidemia have been published one after another with the development of Evidence-based Medicine and the completion of numerous randomized multicenter clinical trials. All of these guidelines have great impact on the management of Chinese patients with CVD, especially of patients with NSTEACS. However, there are still many problems unsolved in the study of NSTEACS in China:(1) 《ACC/AHA Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction》 was issued in October 2002. It has been four years since then. However, little was known about the impact of this guideline on the management and prognosis of patients with NSTEACS.(2) Whether there is significant difference in the outcomes of patients with NSTEACS with different age and gender?(3) Whether there is significant difference in clinical features and in-hospital management of patients with NSTEACS with different age and gender?Objective(1) To evaluate the impact of 《ACC/AHA Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction》 issued in October 2002 on the outcomes of hospitalized patients.(2) To evaluate the difference in the outcomes of patients with NSTEACS with different age and gender .(3) To investigate the difference in clinical features and in-hospital management of patients with NSTEACS with different age and gender.Patients and methods1. PatientsAll patients who were admitted to our hospital between January 1998 and August 2006 with a definite diagnosis of NSTEACS were included in the present study. A total of 1,363 patients with NSTEACS including 904 males and 459 females were enrolled with the mean age being 63.6±11.1 years.2. MethodsA detailed review of the medical record was made in each patient and clinical variables including baseline characteristics, in-hospital management, and the incidence of adverse events during hospitalization were analyzed. Baseline characteristics consisted of age, gender, cigarette smoking, history of angina pectoris, myocardial infarction, hypertension, diabetes mellitus, transient ischemia attach(TIA),hemorrhagic apoplexy, cerebral arterial thrombosis and disease of blood vessel,family history of coronary artery disease, heart rate,blood pressure,blood glucose,blood fat and Killip classification of cardiac function. Analysis of in-hospital management involved beta-receptor blockers, aspirin, ADP receptoe inhibitor (clopidogrel or ticlopidine), heparins, angiotensin-converting-enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), statins, calcium antagonists, nitrates. Patient's adverse outcomes were defined as CHF and death during hospitalization.3. Statistical analysisStatistical analyses were performed using Excel 2003 and SPSS 11.0 for PC. Values were expressed as mean ± standard deviation (X±SD) for continuous variables and number and percentage (%) for binary or polynary variables. Comparisons among different groups were made by a two-tailed Student test for continuous variables and by Pearson chi-square test and Fisher's exact test for binary variables. Difference were regarded as statistically significant when P values was < 0.05. Comparisons among polynary variables (≥3 groups) were made by chi-square test for R×C table and further analyses were performed when significant difference (P<0.05) was found among total groups. Comparisons among each of the two different groups were made by chi-square test for subdividing RxC table and difference were regarded as statistically significant when P values was less than 0.10/ k(k-1). The word "k" refers to the number of the groups being tested. Results1. The impact of 《ACC/AHA Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction》 issued in October 2002 on the outcomes of hospitalized patients.There are 516 patients before the guideline issued and there are 847 patients after it.1.1 Patients' baseline characteristics on admission before and after the guideline issuedThese baseline characteristics before and after the guideline issued were quite similar and no significant difference between these two groups was found. Baseline characteristics consisted of history of cigarette smoking (35.7% vs 34.2%, P=0.593), family history of coronary artery disease (7.0% vs 6.8%, P=0.592), TIA(0.8% vs 1.2%,P=0.418),hemorrhagic apoplexy(0.8% vs 0.7%,P=0.538), cerebral arterial thrombosis(14.0% vs 11.3%,P=0.201) and diabetes mellitus (17.8% vs 21.1%, P= 0.138),. But age (61.6±12.1 years vs 64.9+ 10.3years, P<0.001)is higher, the rate of female increases (males, 72.1% vs 62.8%, P<0.001)(female,27.9% vs 37.2%, P<0.001), the incidence of hypertension and myocardial infarction[ (47.3% vs 60.6%, P<0.001) (45.0% vs 28.9%, P<0.001)] raises up.1.2 In-hospital managementThere were no significant differences in the administration of Ca-antagonist and nitrates before and after the guideline issued (and 60.5% vs 62.2%, P=0.527,and 96.1% vs 94.3%, P =0.133 respectively). More patients have undergone interventional therapy since the guideline issued in October 2002 (33.2% vs 24.0%, P<0.001). aspirin, ADP receptor antagonist, ACEI and/or ARB , β— blockers, statins and heparins were used more commonly during hospitalization after the guideline issued (87.6% vs 93.8%, P 0.001,35.1% vs 66.2%, P<0.001; 69.0% vs 74.7%, P=0.023; 62.8% vs 75.3%, P<0.001; 28.9% vs 71.0%, P<0.001; and 55.8% vs 76.7%, P< 0.001, respectively).1.3 In-hospital adverse eventsThe occurrence rate of congestive heart failure and death was lower after the guideline issued in 2002(15.5% vs 10.5%, P<0.001 and 4.7% vs 1.4%, P<0.001, respectively). 2. Impact of age and gender on in-hospital outcomes of patients with NSTEACS 904 males and 459 females were enrolled in this study. The distribution by ageswas: ≤60 years, 454 patients (33.3%); 61 to 80 years, 822 (60.3%); and≥81 years, 87(6.4%).2.1 Impact of age on in-hospital outcomes of patients with NSTEACSThe relative proportion of females increased with age (12.8%, 42.9% and 55.8% for patients ≤60, 61 to 80 and ≥81 years of age, all P<0.001). The incidence of CHF (6.2%, 12.9% and 39.5% for ≤60, 61 to 80 and ≥81 years of age, all P< 0.001 ) and death (0.9%, 2.9% and 9.3% for ≤60, 61 to 80 and ≥81 years of age, all P<0.001) during hospitalization was increased with age too.2.2 Impact of gender on in-hospital outcomes of patients with NSTEACS There was no significant difference on the incidence of death between male andfemale patients (2.4% vs 3.1%P=0.502), but females were more likely to have congestive heart failure during hospitalization than males (10.6% vs 16.0%, P= 0.005).3. Investigation the difference in clinical features and in-hospital management of patients with NSTEACS with different age and gender.A total of 1,363 patients with NSTEACS including 904 males and 459 females with the mean age being 63.6±11.1 years were enrolled in the present study. There were 909 old (≥60 years) and 454 non-old (<60 years) enrolled in this study.3.1 Baseline characteristics on admission between male and female patients with NSTEACSFemales were substantially older than males (68.6±8.2 vs 61.1±11.5 years, P< 0.001) and had a higher prevalence of hypertension (74.7% vs 45.8%, P<0.001) and diabetes mellitus (27.7% vs 15.9%, P<0.001). Total cholesterol and low density lipoprotein were higher in females (6.5± 1. 2 vs 6. 0±1. 4 , 4.0 ± 0. 8 vs 3.4 ± 0. 9, all P< 0.001, respectively). There was no significant difference on the family coronary heart disease between males and females (7.7% vs 5.2%, P = 0.132). However, history of previous myocardial infarction and cigarette smoking were more common in males (40.3% vs 24.8%, and 49.3% vs 6.1%, P<0.001, respectively).3.2 In-hospital management between male and female patients with NSTEACSFemales were less likely to receive reperfusion therapy (19.8% vs 34.7%, P<0.001) duraing in-hospital stay. Furthermore, aspirin,ADP receptor inhibitor , angiotensin-converting-enzyme inhibitors (ACEI) and/or angiotensin receptor blockers(ARB ) and calcium antagonists were underused in females during the hospitalization phase (87.3% vs 93.6%, P<0.001,and 47.9% vs 57.7%,P<0.001,69.9% vs 77.7%,P<0.005, 59.5% vs 65.6%, P = 0.031). There was difference in the administration of other pharmacological measures including β—blockers(67.3% vs 72.1%, P = 0.068) and heparin(67.0% vs 72.2% ,P=0.054),but no statistical significance. There was no significant difference in the administration of other pharmacological measures including statins (56.8% vs 54.2%, P=0.367), nitrates (94.7% vs 95.1%, P=0.732) between males and females.3.3. Baseline characteristics on admission between old and non-old patients with NSTEACSThere were more female patients in the old-age group than in the non-old-age group (44.0% vs 12.8%, P<0.001). Patients old myocardial infarction (36.9% vs 34.0%, P=0.071) were more common in the old-age group than in the non-old-age group. The prevalence of hypertension (62.3% vs 41.6%, P<0.001) and diabetes mellitus (23.3% vs 12.8%, P<0.001) in the old-age group was higher than that in non-old-age group. Non-old patients were more likely to have the history of cigarette smoking and family history of coronary artery disease (51.8% vs 26.2%, 12.4% vs 4.0%, all P< 0.01).3.4 In-hospital management between old and non-old patients with NSTEACSOld patients were less likely to receive interventional therapy than non-old patients (23.0% vs 42.9%, P<0.001). Aspirin, ADP receptor inhibitor, Beta-blockers, ACEI/ARB and calcium antagonists were underused in old patients (89.6% vs 95.1%, 50.5% vs 61.9%, 67.4% vs 76.5% , 63.7% vs 77.0% and 55.3% vs 64.5%, all P< 0.001).There was no significant difference in the admistration of nitrates, lipid regulating agents and heparins antiplatelets (95.8% vs 93.8%, P=0.111, 55.2% vs 54.9%, .P=0.912 and 70.0% vs 65.9%, P=0.125) between old and non-old patients.Conclusions1. The guideline for the management of patients with NSTEACS issued in Octorber 2002 produced a great impact on the therapy standardization and led to a significant improvement of in-hospital outcomes in patients with NSTEACS.2. Age had great impact on the occurrence rate of complications in patients with NSTEACS. The incidence of in-hospital congestive heart failure and death increased with age. There was no significant difference on the incidence of death between male and female patients, but females were more likely to have congestive heart failure during hospitalization than males.3. There were different on the clinical features and in-hospital management between male and female patients. Females were older and had more risk factors than males, interventional therapy and beta-blockers were underused in females, There was significant difference on the in clinical features, in-hospital management and outcomes incidence of congestive heart failure and death between old and non-old patients.
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