instituted to help reinforce the importance of compliance with the medications after discharge, as well as lipid management and smoking cessation. Key words: ...
Clin. Cardiol. 24, 114-1 18 (2001)
Intervention to Improve Adherence to ACC/AHA Recommended Adjunctive Medications for the Management of Patients with an Acute Myocardial Infarction SANDRA s.AXTELL, PHARM.D., EL~ABETH LUDWIG, PHARM.D., A. LOPEZ-CANDALES, M.D.* Department of Phannacy and *Division of Cardiology at The Buffalo General Hospital, State University of New York at Buffalo, Buffalo, New York, USA
Summary
Background: The most recent published guidelines regarding management of patients surviving an acute myocardial in-. farction (AMI) advocate the administrationof aspirin (ASA), beta blockers (BB), and angiotensin-converting enzyme inhibitors (ACEi) and discourages the use of calcium-channel blockers (CCB). Previous data collected in our region from the National Registry (NR) showed a dismal compliance with these guidelines.In an attempt to increasephysician awareness and to optimize implementationof recommended guidelines, a cardiac and pharmacy steering committee was created. Methods: The pharmacist assigned to the project identified all patients admitted with an AM1 using troponin-I and creatine kinase-MB (CK-MB) reports. The pharmacist then contacted physicians to make recommendations if an adjunctive medication was not prescribed for a patient with no apparent contraindications. Administration rates for ASA, BB, ACEi, and CCB were then assessed and compared with the previously obtained baseline data from the NR. Results: At admission, the use of ASA increased from 70 to 72%,BB from 45 to 72%,and ACEi from 12to 44%. In terms of medications at discharge, ASA use increased from 74 to 88%. BB from 55 to 76%,and ACEi from 30 to 40%. In addition, the prescription rates for CCB at discharge decreased from 36 to 21%.
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Address for reprints: Angel Lopez-Candales, M.D., F.A.C.C. Director, Coronary Care Unit Cardiology Division The Buffalo General Hospital Buffalo, NY 14203, USA Received: February 15. 2000 Accepted with revision: April 26, 2000
Conclusions: An interdisciplinary approach for disease management is an effective method for improving adherence to treatment guidelines simply with pharmacy intervention. The percentage of patients receiving the recommended adjunctive medications increased significantly.We propose that these guidelines should be periodically inserviced to physicians. Furthermore,patient counseling sessions should also be instituted to help reinforce the importance of compliance with the medications after discharge, as well as lipid management and smoking cessation.
Key words: acute myocardial infarction, angiotensinconverting enzyme inhibitors,aspirin, beta blockers, treatment guidelines, pharmacist
Introduction The American College of Cardiology and the American Heart Association (ACC/AHA) guidelines for the management of patients with an acute myocardial infarction (AMI) advocate the administration of aspirin (ASA), beta blockers (BB),and angiotensinconvertingenzyme inhibitors (ACEi). Similarly,they discouragethe use of calciumchannelblockers (CCB).I Aspirin should be given immediately upon admission and then continued indefinitely on a daily basis. In the presence of a true allergy to aspirin, ticlopidine or clopidrogel should be substituted. Beta blockers should be instituted for patients without contraindications within 12 h of onset of infarction.I4 The intravenous route should be used for patients considered to be at high risk and oral agents for the low- or intermediaterisk patients. Angiotensin-convertingenzyme inhibitors should be used within the fmt 24 h of a suspected AM1 in patients who present with ST-segment elevation in the anterior leads. Angiotensinconverting enzyme inhibitors are also recommended in patients with clinical heart failure, patients with both a myo-
S.S. Axtell et af.: Improving the management of patients with MI
cardial infarction and a left ventricularejection fraction that is c 40%. and in asymptomatic patients with a previous myocardial infarction whose left ventricularejection fraction is mildly reduced.1-4.5 Conversely,the ACUAHA discourages the use of the CCB because they have not been proven to reduce mortality, and in filct several reports have shown that, when used in the acute setting of a myocardial infarction, they may be detrimental by increasing morbidity and mortality.1+6 In a previous report from the Cooperative Cardiovascular Project, 77.8% of the patients surviving an AM1 were discharged on ASA, 49.5%on BB, and 59.3% on ACEi.’ By the nature of the analysis, the reported percentages reflect the actual number of ideal patients receiving the recommended medications.
Methods Baseline data collected from the National Registry on 960 patients admitted with an AM1 from the Western New’York region revealed that 74%of the patients discharged after an AM1 received ASA, 55% received a BB, and 30%received an ACEi8 In view of these suboptimal results, we created an interdisciplinary Cardiology Quality Management Project that consisted of clinical pharmacists,guided by the Departmentof Cardiology at a tertiary teaching hospital, to evaluate the impact of a simple strategy in physician awareness of the recommended guidelines for the management of survivors of an AM1 as published by the ACUAHA. The clinical pharmacists identified all patients admitted with an AMI. Troponin-I and creatine kinase-MB (CK-MB) reports were faxed daily to the pharmacy ofice. During Phase I, a concise summary of the ACWAHA guidelines for the management of AM1 was placed in the charts of the patients admitted with an AMI. In Phase 11, in addition to the guidelines placed in patients’ charts, a clinical pharmacist then contacted physicians to make recommendationsif an adjunctive medication was not prescribed for a patient with no apparent contraindications. During Phase I of the study, 50 consecutivepatients, admitted between November 1998 and December 1998 to the comnary care unit of the Buffalo General Hospital with an AMI, were included in this study. Patients were treated by their corresponding physicians.The administrationrates for ASA, BB, and ACEi upon admission and at discharge were then determined for these patients. These results were then compared with the baseline data previously collected for the Western New York region. During Phase I1 of the study, 50 consecutive patients, admitted between March 1999 and April 1999 to the coronary care unit of the Buffalo General Hospital with the diagnosis of an AMI, were included in this study. The method of identifying patients and their inclusion criteria were similar to those described in Phase 1. Known contraindicationsfor the use of ASA, BB, and ACEi were determined for these patients and then compared with the baseline and Phase I data.
I I5
In Phase II,36% of the patients’ physicians were contacted to encourage use of the suggested medications that had no apparent contraindications. The chi-square statistics were used to assess statistical significance for all categorical variables. A p value of < 0.05 was considered significant.
Results The percentage of patients 265 years of age was 52% in the baseline study, 58% in Phase I, and 52%in Phase 11. There was no apparent difference in age dispersion between the study groups. In our study, 58% were men during Phase I and 72% were men in Phase 11. Noteworthy for this study is that many of the patients were transferred from an outside facility. This fact could greatly influence the results of the percentage of medications administered at admission since the transfer patients were subject to the prescribing patterns of that particular facility. The overall use of ASA, BB, and ACEi upon admission increased for both Phases I and I1 compared with baseline, as shown in Table I. There was no significant increase in the prescription rates for ASA during admission. At baseline, it was found to be 70%; 76% (p = 0.36) for Phase 1 and 72% (p = 0.76) for Phase 11. Prescription rates for BB within 12h of admission increased from 45%at baseline to 74% (p c 0.05) for Phase I and 72% (p
