Trends and variations in the prescribing of secondary preventative cardiovascular therapies for non-ST elevation myocardial infarction (NSTEMI) in Malaysia

Abstract

PurposeInformation is lacking on prescribing of preventative cardiovascular pharmacotherapies for patients with non-ST elevation myocardial infarction (NSTEMI) in the Asian region. This study examined the prescribing rate of these pharmacotherapies, comparing NSTEMI to STEMI, and variations across demographics and clinical factors within the NSTEMI group in the multi-ethnic Malaysian population.MethodsThis is a retrospective analysis of the Malaysian National Cardiovascular Disease Database-Acute Coronary Syndrome registry from year 2006 to 2013 (n = 30,873). On-discharge pharmacotherapies examined were aspirin, ADP-antagonists, statins, ACE-inhibitors, angiotensin-II-receptor blockers, and beta-blockers. Multivariate logistic regression was used to calculate adjusted odds ratio of receiving individual pharmacotherapies according to patients’ characteristics in NSTEMI patients (n = 11,390).ResultsPrescribing rates for cardiovascular pharmacotherapies had significantly increased especially for ADP-antagonists (76%) in NSTEMI patients. More than 85% were prescribed statins and antiplatelets but rates remained significantly lower compared to STEMI. Women and those over 65 years old were less likely to be prescribed these pharmacotherapies compared to men and younger NSTEMI patients. Chinese and Indians were more likely to receive selected pharmacotherapies compared to Malays (main ethnicity). Geographical variations were observed; East Malaysian (Malaysian Borneo) patients were less likely to receive these compared to Western region of Malaysian Peninsular. Underprescribing in patients with risk factors such as diabetes were observed with other co-morbidities influencing prescribing selectively.ConclusionThis study uncovers demographic and clinical variations in cardiovascular pharmacotherapies prescribing for NSTEMI. Concerted efforts by policy makers, specialty societies, and physicians are required focusing on elderly, women, Malays, East Malaysians, and high-risk patients.Electronic supplementary materialThe online version of this article (10.1007/s00228-018-2451-3) contains supplementary material, which is available to authorized users.

Invasive and antiplatelet treatment of patients with non‐ST‐segment elevation myocardial infarction: Understanding and addressing the global risk‐treatment paradox

“…Optimal guideline‐indicated treatment of patients with NSTEMI is also affected by the availability of procedures, as well as governmental and hospital policies. Several studies have demonstrated wide geographical variation in the use of guideline‐indicated treatments for patients with NSTEMI, which is linked to hospital and geographical characteristics …”

“…A study using the Malaysian National Cardiovascular Disease Database—ACS (NCVD‐ACS) registry showed geographical variations in prescribing rates for secondary preventive medications in patients with NSTEMI . For example, patients in East Malaysia were less likely to be prescribed P2Y 12 inhibitors or aspirin than patients in the Western region of the Malaysian Peninsular …”

“…Aside from differences in the availability of specialist services, variation in healthcare for patients with NSTEMI across hospitals could also be due to differences in: the number of hospital admissions; national guidelines and hospital protocols; clinicians' treatment decisions; cost of and access to new and effective medications; and healthcare system procurement, infrastructure, and funding …”

“…Several studies have demonstrated wide geographical variation in the use of guideline-indicated treatments for patients with NSTEMI, which is linked to hospital and geographical characteristics. 30,[55][56][57] In the SNAPSHOT ACS study, assessing patients with chest pain admitted to hospitals in Australia and New Zealand, the proportion of patients with NSTEMI who were given a coronary angiogram varied from 56.5% to 68.9% across health jurisdictions, whereas the proportion of patients with STEMI/left bundle branch block given a coronary angiogram ranged from 81.1% to 100%. 30 Registry data from Arabian Gulf countries (Saudi Arabia, Bahrain, Qatar, Oman, United Arab Emirates, and Yemen) showed that only 26.8% of patients with NSTEMI received coronary angiography and 21.9% received revascularization with either PCI or CABG.…”

“…57 For example, patients in East Malaysia were less likely to be prescribed P2Y 12 inhibitors or aspirin than patients in the Western region of the Malaysian Peninsular. 57 In China, a nationwide database study that included 1055 tertiary hospitals showed an in-hospital mortality of 3.6% and a PCI utilization rate of 37.2% in patients with NSTEMI (corresponding rates in patients with STEMI were 5.1% and 47.8%, respectively). 55 The study identified wide variations in the rates of in-hospital mortality across geographical regions, and the rates were significantly lower in patients who received PCI than in those who did not.…”