Optimal medical therapy at discharge in patients with acute coronary syndromes: Temporal changes, characteristics, and 1-year outcome

Division of Cardiology, Canadian Heart Research Centre, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.
American heart journal (Impact Factor: 4.46). 12/2007; 154(6):1108-15. DOI: 10.1016/j.ahj.2007.07.040
Source: PubMed


There are limited data on the recent trend in the use of optimal evidence-based medical therapies after acute coronary syndromes (ACSs). We sought to evaluate (1) the temporal changes in medical management of patients discharged after an ACS; (2) patient and practice characteristics associated with optimal medical therapy at discharge; and (3) the association between discharge medication use and 1-year outcome.
The Canadian ACS I (September 1999-June 2001) and ACS II (October 2002-December 2003) Registries were prospective, multicenter, observational studies of 6853 patients admitted for ACS. We examined the discharge use of medications among 5833 hospital survivors who did not have any contraindications to antiplatelet/anticoagulant, beta-blocker, angiotensin-converting enzyme inhibitor, or lipid-modifying therapies. Optimal medical therapy was defined as the use of all indicated medications. Follow-up data at 1 year were collected by telephone interview. We performed hierarchical logistic regression to identify patient characteristics and care patterns associated with optimal medical treatment and to examine its relationship with 1-year mortality.
There were significant increases in the discharge use of all 4 classes of medications over time; 28.9% and 51.8% of patients in ACS I and ACS II Registries, respectively, were prescribed optimal medical therapy (P < .001). Advanced age, female sex, prior heart failure, renal dysfunction, and coronary bypass surgery during hospitalization were negative independent predictors of optimal medical therapy. Conversely, enrollment in ACS II Registry, history of dyslipidemia, presence of ST elevation and abnormal cardiac biomarker, previous myocardial infarction, and previous coronary revascularization were independently associated with the use of combination therapy. After adjusting for other validated prognosticators, patients receiving optimal medical therapy had significantly lower 1-year mortality (adjusted odds ratio 0.54, 95% confidence interval 0.36-0.81, P = .003) compared with those given 0 or 1 drug at discharge. Over the 1-year follow-up period, substantial numbers of patients discontinued therapies, whereas others were initiated on treatment.
Despite the temporal increases in the combined use of evidence-based pharmacologic therapies, which is associated with improved outcome, medical management of ACS remains suboptimal. Quality improvement strategies are needed to enhance the appropriate use of effective therapies, targeting specifically the high-risk but undertreated patients who may derive the greatest therapeutic benefit.

6 Reads
  • Source
    • "However, previous studies reported that not all patients are treated according to these guideline-recommended strategies [14, 15]. For example, patients with higher age, female sex, prior heart failure, renal insufficiency or coronary artery bypass graft (CABG) surgery during admission were less likely to receive guideline-recommended discharge medication [16]. Also, variation in guideline adherence between hospitals has been reported [10]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Increasing guideline adherence in the management of acute coronary syndrome (ACS) in hospitals potentially reduces heart failure and mortality. Therefore, an expert panel identified three guideline recommendations as the most important aims for improvement in ACS care, i.e. timely invasive treatment, use of risk scoring instruments and prescription of secondary prevention medication at discharge. Aims This study aims to evaluate in-hospital guideline adherence in the care of patients diagnosed with ACS and to identify associated factors. Methods The study has a cross-sectional design. Data are collected in 13 hospitals in the Netherlands by means of retrospective chart review of patients discharged in 2012 with a diagnosis of ACS. The primary outcomes will be the percentages of patients receiving timely invasive treatment, with a documented cardiac risk score, and with a prescription of the guideline-recommended discharge medication. In addition, factors associated with guideline adherence will be studied using generalised linear (mixed) models. Discussion This study explores guideline adherence in Dutch hospitals in the management of patients diagnosed with ACS, using a data source universally available in hospitals. The results of this study can be informative for professionals involved in ACS care as they facilitate targeted improvement efforts.
    Full-text · Article · Jul 2014 · Netherlands heart journal: monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation
  • Source
    • "48 93 45 80 70 76 Korea AMI registry [18] 50 99 NA 77 73 82 Expanded GRACE (ST-elevation) b [17] NA 96 90 86 81 79 Canadian ACS II [6] "
    [Show abstract] [Hide abstract]
    ABSTRACT: To evaluate the impact of evidence-based cardiac medications (EBMs) on 1-month and 1-year mortality among discharged acute coronary syndrome (ACS) patients in the Middle East. Data were analyzed from 7,567 consecutive ACS patients admitted to 66 hospitals in 6 Middle Eastern countries enrolled in the Gulf RACE II in October 2008 to June 2009. Individual EBMs or concurrent use of the EBM combination consists of an anti-platelet therapy, angiotensin-converting enzyme inhibitor (ACEI) (or angiotensin II receptor blocker (ARB)), β-blocker, and a statin at discharge, were evaluated. Analyses were performed using univariate and multivariate statistical techniques. The mean age of the cohort was 56 +/- 12 years with 79% being males. 65% of the patients received the concurrent EBM combination at discharge. Aspirin, clopidogrel, statins, b-blockers and ACEIs/ARBs use was 96%, 71%, 95%, 82% and 81%, respectively. 70% of the patients were prescribed both aspirin and clopidogrel concurrently at discharge. Adjusting for demographic, clinical, revascularization, and country characteristics, the multivariable logistic regression models demonstrated no differences in mortality at both 1-month (3.0 vs. 3.6%; p = 0.828) and 1-year (3.5 vs. 3.5%; p = 0.976) between the concurrent EBM combination users and non-users. The majority of the ACS patients in the Middle East were prescribed the guideline recommended EBM combination at discharge. However, potential still remains for further optimization of management. Further studies are required to examine the long term effect of concurrent use of the EBM combination on mortality in the region.
    Full-text · Article · Apr 2012 · International journal of clinical pharmacology and therapeutics
  • Source
    • "Mortality rates reported elsewhere varied widely [6,15-17]. A positive relationship between adherence to evidence-based pharmacotherapy and survival following AMI has been reported [18,19]. To date, several risk scores have been suggested to aid treatment decisions. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Mortality from cardiovascular disease in Estonia is among the highest in Europe. The reasons for this have not been clearly explained. Also, there are no studies available examining outpatient drug utilization patterns in patients who suffered from acute myocardial infarction (AMI) in Estonia. The objective of the present study was to examine drug utilization in different age and gender groups following AMI in Estonia. Patients admitted to hospital with AMI (ICD code I21-I22) during the period of 01.01.2004-31.12.2005 and who survived more than 30 days were followed 365 days from the index episode. Data about reimbursed prescriptions of beta-blockers (BBs), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs) and statins for these patients was obtained from the database of the Estonian Health Insurance Fund. Data were mainly analysed using frequency tables and, where appropriate, the Pearson's chi2 test, the Mann-Whitney U-test and the t-test were used. A logistic regression method was used to investigate the relationship between drug allocation and age and gender. We presented drug utilization data as defined daily dosages (DDD) per life day in four age groups and described proportions of different combinations used in men and women. Four thousand nine hundred patients were hospitalized due to AMI and 3854 of them (78.7%) were treated by BBs, ACE/ARBs and/or statins. Of the 4025 inpatients who survived more than 30 days, 3799 (94.4%) were treated at least by the one of drug groups studied. Median daily dosages differed significantly between men and women in the age group 60-79 years for BBs and ACE/ARBs, respectively. Various combinations of the drugs studied were not allocated in equal proportions for men and women, although the same combinations were the most frequently used for both genders. The logistic regression analysis adjusted to gender and age revealed that some combinations of drugs were not allocated similarly in different age and gender groups. Most of the patients were prescribed at least one of commonly recommended drugs. Only 40% of them were treated by combinations of beta-blockers, ACE inhibitors/angiotensin II receptor blockers and statins, which is inconsistent with guideline recommendations in Estonia. Standards of training and quality programs in Estonia should be reviewed and updated aiming to improve an adherence to guidelines of management of acute myocardial infarction in all age and gender groups.
    Full-text · Article · Jun 2010 · BMC Public Health
Show more