Utilization of Ticagrelor in the Upstream Setting for Non-ST-Segment Elevation Myocardial Infarction (UPSTREAM): An ED-Based Clinical Registry

This is a Phase IV, post-approval, multicenter, prospective, noninterventional study of
consecutive patients with a working diagnosis of NSTEMI (Non-ST-Elevation Myocardial
Infarction) and treatment with an OAP (Oral Anti-Platelet) agent (ticagrelor, clopidogrel, or
prasugrel) either in the ED (Emergency Department), or in any case within the timeframe that
emergency physicians consider to be "upstream"- i.e., within the first 72 hours after ED
arrival and at least 4 hours before diagnostic angiography. This registry is designed to
address the data gap regarding the course of NSTEMI between ED arrival and diagnostic
angiography in detail, by characterizing and following the ED and peri-ED use of advanced OAP
agents.

Demographic, ischemic vs bleeding risk stratification [calculated retrospectively by GRACE
(Global Registry of Acute Coronary Events), TIMI (Thrombolysis in Myocardial Infarction), and
PURSUIT (Platelet glycoprotein IIb/IIIa in Unstable angina: Receptor Suppression Using
Integrilin) scores, and CRUSADE (Can Rapid risk stratification of Unstable angina patients
Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines) Bleeding
Score, respectively], and OAP agent data (including, when discernible, rationale for agent
selection) will be collected for all UPSTREAM patients, regardless of OAP therapy, through
discharge. Risk factors, angiography results, intervention/s (if any), post-catheterization
care, discharge regimens, and in-hospital outcomes will be recorded.

Patients who are treated upstream, in-hospital, and are discharged home on ticagrelor, will
be further followed up, by telephone and/or chart review (if necessary elements are included
in chart accessible to investigator), at 30 (+10) days post-discharge, during which
evaluation data elements to be collected include patient-reported compliance with visits and
medications, patient-reported healthcare resource utilization, and any pertinent events or
complications.

Patients who are treated upstream, in-hospital, or discharged home on a different OAP therapy
(clopidogrel or prasugrel) will not be followed beyond the data collection completed at
hospital discharge. It is expected that a relatively small number of patients will change
therapy from ticagrelor to another OAP agent after discharge and prior to 30 days
post-discharge, though such changes will be queried in the 30-day call/chart review.

Inclusion Criteria:

Patients (≥18 years of age) with a working diagnosis of NSTEMI and treatment with an OAP
agent (ticagrelor, clopidogrel, or prasugrel) either in the ED, or in any case within the
timeframe that emergency physicians consider to be "upstream"- i.e., within the first 72
hours of care and at least 4 hours before diagnostic angiography. In addition, only those
patients who undergo a diagnostic coronary angiography within 72 hours of ED arrival will
be eligible for UPSTREAM.

Exclusion Criteria:

1. Life expectancy less than 90 days in opinion of treating clinician;

2. Not undergoing diagnostic angiography within 72 hours of ED arrival;

3. Refusal of consent; or

4. Unlikely to comply with follow-up by telephone.