The Upstream Registry

This registry seeks to characterize the in-hospital outcomes on NSTEMI patients treated with OAP agents in the upstream interval of care.

UPSTREAM is supported through a collaborative research grant from AstraZeneca Pharmaceuticals (Wilmington, DE; The registry is listed on as protocol NCT02271022.

Hospital Quality Foundation

Medical care of invasively managed NSTEMI patients can be divided into two phases: “upstream” and “downstream.”  The upstream interval encompasses all care provided prior to diagnostic angiography and therefore includes the clinical ischemic/bleeding risk stratification, empiric decision-making, and diagnostic and therapeutic actions of emergency medical services personnel, emergency physicians, hospitalists and other internists, and non‑interventional cardiologists.  Downstream care is post-angiographic and therefore is driven by knowledge of the coronary anatomy.  Downstream management decisions include choosing between percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) surgery, or informed medical management strategies, are initially made by cardiologists in the catheterization lab, and ultimately involve shared decision-making among some combination of interventionalists, hospitalists, other internists, and the patient’s primary care provider.

A knowledge gap exists with regards to details of the course of treatment for patients with NSTEMI between emergency department (ED) arrival and diagnostic angiography.  The UPSTREAM Registry seeks to fill that gap for patients receiving oral antiplatelet therapy during the upstream interval.

Oral antiplatelet therapy is appropriate in the upstream setting in patients whose likely antithrombotic benefit from treatment outweighs the increased likelihood of bleeding complications inherent in upstream loading.  According to current American College of Cardiology / American Heart Association (ACC/AHA) Guidelines regarding the management of NSTE-ACS, the use of ticagrelor is preferred over clopidogrel in patients treated with an early invasive strategy and/or coronary stenting.  In addition, ticagrelor also has a Class I recommendation for the treatment of patients with NSTE-ACS undergoing early invasive management and/or coronary stenting.   Both ticagrelor and clopidogrel are suitable as OAP for upstream use in patients with NSTEMI, unless there are substantial bleeding concerns or there is a high clinical likelihood of near-term CABG.  Contemporary ACS registries provide evidence that prasugrel is also sometimes used in this setting, even though it is not indicated for the upstream management of NSTEMI.  There is, in fact, limited data currently available on the safety and efficacy specifically of upstream OAP.

This registry seeks to characterize the in-hospital outcomes of NSTEMI patients treated with any of these three OAP agents in the upstream interval but will collect data for 30 (+10) days post-hospital discharge for those patients treated specifically with ticagrelor.

If you think your emergency department/hospital would be appropriate for participation in UPSTREAM, complete the questionnaire below. Participation in UPSTREAM is limited to sites in the United States only.

The Hospital Quality Foundation is free to join and offers outstanding opportunities for professional collaboration & training for hospital-based clinicians.