Prescription of secondary prevention medications, lifestyle advice, and referral to rehabilitation among acute coronary syndrome inpatients: results from a large prospective audit in Australia and New Zealand

Abstract

ObjectiveTo evaluate the proportion of patients hospitalised with acute coronary syndrome (ACS) in Australia and New Zealand who received optimal inpatient preventive care and to identify factors associated with preventive care.MethodsAll patients hospitalised bi-nationally with ACS were identified between 14–27 May 2012. Optimal in-hospital preventive care was defined as having received lifestyle advice, referral to rehabilitation, and prescription of secondary prevention pharmacotherapies. Multilevel multivariable logistic regression was used to determine factors associated with receipt of optimal preventive care.ResultsFor the 2299 ACS survivors, mean (SD) age was 69 (13) years, 46% were referred to rehabilitation, 65% were discharged on sufficient preventive medications, and 27% received optimal preventive care. Diagnosis of ST elevation myocardial infarction (OR: 2.64 [95% CI: 1.88–3.71]; p<0.001) and non-ST elevation myocardial infarction (OR: 1.99 [95% CI: 1.52–2.61]; p<0.001) compared with a diagnosis of unstable angina, having a percutaneous coronary intervention (PCI) (OR: 4.71 [95% CI: 3.67–6.11]; p<0.001) or coronary bypass (OR: 2.10 [95% CI: 1.21–3.60]; p=0.011) during the admission or history of hypertension (OR:1.36 [95% CI: 1.06–1.75]; p=0.017) were associated with greater exposure to preventive care. Age over 70 years (OR:0.53 [95% CI: 0.35–0.79]; p=0.002) or admission to a private hospital (OR:0.59 [95% CI: 0.42–0.84]; p=0.003) were associated with lower exposure to preventive care.ConclusionsOnly one-quarter of ACS patients received optimal secondary prevention in-hospital. Patients with UA, who did not have PCI, were over 70 years or were admitted to a private hospital, were less likely to receive optimal care.

The underutilisation of dual antiplatelet therapy in acute coronary syndrome

“…Patients undergoing PCI were most likely to receive DAPT, an observation consistently reported in other observational studies [5,8], and reflects the accepted view of DAPT following coronary stenting for the vast majority of PCI patients.…”

“…Yet as recently as 2012, a comprehensive Australian and New Zealand audit encompassing over 90% of hospitals across both countries showed that only 63% of ACS patients received a second antiplatelet agent at hospital discharge [8]. In all reported studies, one consistent observation was the difference between prescription of a second antiplatelet for patients following PCI (percutaneous coronary intervention), where rates were higher than for those undergoing CABG or medical management, despite a consistent accumulation of evidence supporting the use of these second agents in each of these contexts [9][10][11] There remains a significant risk of events following an ACS, with mortality in the [12][13][14][15][16][17][18] months following an ACS reported to be 12.6%, and the composite rate of myocardial infarction, stroke or cardiovascular death to be 18.3% [12,13].…”

Underuse of Cardiac Rehabilitation in Workers With Coronary Artery Disease ― Claims Database Survey in Japan ―

“…This trend was similar to that of inpatient CR use, and was consistent with that noted in previous studies. 10,22, 32 These findings suggested that the diagnosis at admission persistently influences the subsequent utilization of CR. As national and international guidelines recommend CR for patients diagnosed with angina and MI, 6-8 the promotion of CR among this patient population is a common challenge worldwide.…”

Providing heart failure rehabilitation in the home via telerehabilitation

“…This approach is recommended for the management of patients with chronic heart failure (CHF) (Selig et al, 2010) and has been shown to increase exercise capacity (Lewinter et al, 2014;Rees et al, 2004), improve quality of life and reduce hospitalisations (Taylor et al, 2014). Despite this overwhelming benefit, there is still an under-utilisation of exercise-based rehabilitation programs across the world (Pack et al, 2015;Piepoli et al, 2015;Redfern et al, 2014). Traditionally these programs are provided by healthcare professionals in centralised facilities .…”

“…However, while these centre-based programs have been shown to be safe and effective (Smart & Marwick, 2004), they are of limited availability and yield low attendance rates. For instance, 46% of eligible patients with acute coronary syndrome had a documented referral to cardiac rehabilitation in Australia and New Zealand (Redfern et al, 2014), and only 30% of these patients actually participated in cardiac rehabilitation despite this being a recommended therapy (Doll et al, 2015;Suaya et al, 2007). In a systematic review of 34 qualitative studies of 1,213 patients, reported barriers for accessing these centre-based cardiac rehabilitation programs include lack of transport and parking, financial cost and competing work and carer commitments (Neubeck et al, 2012).…”