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1.  Trends in the Incidence and Management of Acute Myocardial Infarction From 1999 to 2008: Get With the Guidelines Performance Measures in Taiwan 
Background
The American Heart Association Get With the Guidelines (GWTG) program has improved care quality of acute myocardial infarction (AMI) with important implications for other countries in the world. This study evaluated the incidence and care of AMI in Taiwan and assessed the compliance of GWTG in Taiwan.
Methods and Results
We used the Taiwan National Health Insurance Research Database (1999–2008) to identify hospitalized patients ≥18 years of age presenting with AMI. The temporal trends of annual incidence and care quality of AMI were evaluated. The age‐adjusted incidence of AMI (/100 000 person‐years) increased from 28.0 in 1999 to 44.4 in 2008 (P<0.001). The use of guideline‐based medications for AMI was evaluated. The use of dual antiplatelet therapy (DAPT) increased from 65% in 2004 to 83.9% in 2008 (P<0.001). Angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) was used in 72.6% in 2004 and 71.7% in 2008 (P=NS) and β‐blocker was used in 60% in 2004 and 59.7% in 2008 (P=NS). Statin use increased from 32.1% to 50.1% from 2004 to 2008 (P<0.001). The in‐hospital mortality decreased from 15.9% in 1999 to 12.3% in 2008 (P<0.0001). Multivariable analysis showed that DAPT, ACE inhibitor/ARB, β‐blocker, and statin use during hospitalization were all associated with reduced in‐hospital mortality in our AMI patients.
Conclusions
AMI incidence was increasing, but the guideline‐based medications for AMI were underutilized in Taiwan. Quality improvement programs, such as GWTG, should be promoted to improve AMI care and outcomes in Taiwan.
doi:10.1161/JAHA.114.001066
PMCID: PMC4310397  PMID: 25112555
epidemiology; incidence; myocardial infarction; population
2.  Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: Results of the Saudi project for assessment of coronary events (SPACE) registry 
Objectives
The Saudi Project for Assessment of Coronary Events (SPACE) registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients.
Methods
We conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS (non-ST elevation acute coronary syndrome).
Results
5055 patients were enrolled with mean age ± SD of 58 ± 12.9 years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking (all P < 0.0001). In-hospital medications were: aspirin (97.7%), clopidogrel (83.7%), beta-blockers (81.6%), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (75.1%), and statins (93.3%). Median time from symptom onset to hospital arrival for STEMI patients was 150 min (IQR: 223), 17.5% had primary percutaneous coronary intervention (PCI), 69.1% had thrombolytic therapy, and 14.8% received it at less than 30 min of hospital arrival. In-hospital outcomes included recurrent myocardial infarction (1.5%), recurrent ischemia (12.6%), cardiogenic shock (4.3%), stroke (0.9%), major bleeding (1.3%). In-hospital mortality was 3.0%.
Conclusion
ACS patients in Saudi Arabia present at a younger age, have much higher prevalence of diabetes mellitus, less access to ambulance use, delayed treatment by thrombolytic therapy, and less primary PCI compared with patients in the developed countries. This is the first national ACS registry in our country and it demonstrated knowledge-care gaps that require further improvements.
doi:10.1016/j.jsha.2011.05.004
PMCID: PMC3727434  PMID: 23960654
Acute coronary syndromes; Acute myocardial infarction; Unstable angina; Registry; Saudi Arabia; Middle East
3.  Impact of Exposure to Evidence-Based Pharmacotherapy on Outcomes Following Acute Myocardial Infarction in Older Adults 
Objectives
To assess the impact of exposure to evidence-based medication following hospital discharge for Medicare beneficiaries with acute myocardial infarction (AMI).
Design
A discrete-time hazard model was used to estimate time-to-outcome associated with exposure to four drug classes (angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers (BBs), statins, and clopidogrel) used for post-AMI secondary prevention of cardiovascular events and mortality.
Setting
Medicare administrative data for a 5% random sample of beneficiaries.
Participants
Medicare beneficiaries (n=9,538) hospitalized for an AMI between 4/1/2006 and 12/31/2007 who survived for at least 30 days after discharge. The cohort was followed until death or 12/31/2008.
Measurements
Time-varying exposure was measured as proportion of days covered (PDC) for each quarter during the follow-up period. PDC was classified into five categories (0–0.2; >0.2–0.4; >0.4–0.6; >0.6–0.8; >0.8–1.0). Outcomes were mortality and a composite outcome of death or post-AMI hospitalization.
Results
Over a median follow-up of 18 months, mean PDC rates ranged from 0.37 (clopidogrel) to 0.50 (statins). When comparing the highest versus lowest categories of exposure, the hazard of the composite outcome was significantly lower for all drug classes except BBs [statins, adjusted hazard ratio (aHR) = 0.71, ACEIs/ARBs, aHR = 0.81, clopidogrel, aHR = 0.85, BBs, aHR = 0.93]. All four drug classes were significantly associated with reductions in mortality; the magnitude of effect for the mortality outcome was largest for statins and smallest for BBs. Age modified the effect of statins on mortality.
Conclusion
Use of evidence-based medications for secondary prevention post-AMI is suboptimal in the Medicare population and low exposure rates are associated with significantly higher risk for subsequent hospitalization and death.
doi:10.1111/j.1532-5415.2012.04165.x
PMCID: PMC3541034  PMID: 23003000
Myocardial infarction; Medicare; Pharmacotherapy; Medicare Part D; Secondary prevention
4.  Long-term prognosis of diabetic patients with acute myocardial infarction in the era of acute revascularization 
Background
The long-term prognosis of diabetic patients with acute myocardial infarction (AMI) treated by acute revascularization is uncertain, and the optimal pharmacotherapy for such cases has not been fully evaluated.
Methods
To elucidate the long-term prognosis and prognostic factors in diabetic patients with AMI, a prospective, cohort study involving 3021 consecutive AMI patients was conducted. All patients discharged alive from hospital were followed to monitor their prognosis every year. The primary endpoint of the study was all-cause mortality, and the secondary endpoint was the occurrence of major cardiovascular events. To elucidate the effect of various factors on the long-term prognosis of AMI patients with diabetes, the patients were divided into two groups matched by propensity scores and analyzed retrospectively.
Results
Diabetes was diagnosed in 1102 patients (36.5%). During the index hospitalization, coronary angioplasty and coronary thrombolysis were performed in 58.1% and 16.3% of patients, respectively. In-hospital mortality of diabetic patients with AMI was comparable to that of non-diabetic AMI patients (9.2% and 9.3%, respectively). In total, 2736 patients (90.6%) were discharged alive and followed for a median of 4.2 years (follow-up rate, 96.0%). The long-term survival rate was worse in the diabetic group than in the non-diabetic group, but not significantly different (hazard ratio, 1.20 [0.97-1.49], p = 0.09). On the other hand, AMI patients with diabetes showed a significantly higher incidence of cardiovascular events than the non-diabetic group (1.40 [1.20-1.64], p < 0.0001). Multivariate analysis revealed that three factors were significantly associated with favorable late outcomes in diabetic AMI patients: acute revascularization (HR, 0.62); prescribing aspirin (HR, 0.27); and prescribing renin-angiotensin system (RAS) inhibitors (HR, 0.53). There was no significant correlation between late outcome and prescription of beta-blockers (HR, 0.97) or calcium channel blockers (HR, 1.27). Although standard Japanese-approved doses of statins were associated with favorable outcome in AMI patients with diabetes, this was not statistically significant (0.67 [0.39-1.06], p = 0.11).
Conclusions
Although diabetic patients with AMI have more frequent adverse events than non-diabetic patients with AMI, the present results suggest that acute revascularization and standard therapy with aspirin and RAS inhibitors may improve their prognosis.
doi:10.1186/1475-2840-9-1
PMCID: PMC2815698  PMID: 20047694
5.  Prevalent but moderate variation across small geographic regions in patient non-adherence to evidence-based preventive therapies in older adults post acute myocardial infarction 
Medical care  2014;52(3):185-193.
Background
Patient long-term adherence to β-blockers, HMG-CoA reductase inhibitors (statins), and angiotensin-converting-enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) after acute myocardial infarction (AMI) is alarmingly low. It is unclear how prevalent patient adherence may be across small geographic areas and whether this geographic prevalence may vary.
Methods
This is a retrospective cohort study using Medicare service claims files from 2007 to 2009 with Medicare beneficiaries ≥ 65 years who were alive 30 days after the index AMI hospitalization between 1/1/2008 to 12/31/2008 (N=85,017). The adjusted proportions of patients adherent to β-blockers, statins, and ACEIs/ARBs respectively in the 12 months after discharge across the 306 Hospital Referral Regions (HRRs) were measured and compared by control chart. The intracluster correlation coefficient (ICC) and the additional prediction power from this small-area variation on individual patient adherence were assessed.
Results
The adjusted proportion of patients adherent across HRRs ranged from 58% to 74% (median, 66%) for β-blockers, from 57% to 67% (median, 63%) for ACEIs/ARBs, and from 58% to 73% (median, 66%) for statins. The ICC was 0.053 (95% CI, 0.043–0.064) for β-blockers, 0.050 (95% CI, 0.039–0.061) for ACEIs/ARBs, and 0.041 (95% CI, 0.031–0.052) for statins. The adjusted proportion of patients adherent across HRRs increased the c-statistic by 0.01 to 0.02 (P<0.0001).
Conclusions
Non-adherence to evidence-based preventive therapies post AMI among older adults was prevalent across small geographic regions. Moderate small-area variation in patient adherence exists.
doi:10.1097/MLR.0000000000000050
PMCID: PMC4359969  PMID: 24374416
compliance/adherence; small area variation; acute myocardial infarction; Secondary prevention; Medication Adherence; Regional Variation
6.  Gender-related differences in the presentation, management, and outcomes among patients with acute coronary syndrome from Oman 
Objective
To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome (ACS) patients from Oman.
Methods
Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were conducted using univariate and multivariate statistical techniques.
Results
In this study, 608 (39%) patients were women with mean age 62 ± 12 vs. 57 ± 13 years (p < 0.001). More women were seen in the older age groups (age <55 years: 25% vs. 43%, 55–74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001). Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction (STEMI), non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants (88% vs. 79%; p < 0.001), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (70% vs. 65%; p = 0.050) more and clopidogrel less (20% vs. 29%; p < 0.001). Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality (4.6% vs. 4.3%) even after adjusting for age (p = 0.500).
Conclusions
Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel.
doi:10.1016/j.jsha.2010.09.003
PMCID: PMC3727510  PMID: 23960630
Gender-related differences; Women; Acute coronary syndrome; Oman
7.  Cost-Effectiveness of Optimal Use of Acute Myocardial Infarction Treatments and Impact on Coronary Heart Disease Mortality in China 
Background
The cost-effectiveness of the optimal use of hospital-based acute myocardial infarction (AMI) treatments and their potential impact on coronary heart disease (CHD) mortality in China is not well known.
Methods and Results
The effectiveness and costs of optimal use of hospital-based AMI treatments were estimated by the CHD Policy Model-China, a Markov-style computer simulation model. Changes in simulated AMI, CHD mortality, quality-adjusted life years, and total healthcare costs were the outcomes. The incremental cost-effectiveness ratio was used to assess projected cost-effectiveness. Optimal use of 4 oral drugs (aspirin, β-blockers, statins, and angiotensin-converting enzyme inhibitors) in all eligible patients with AMI or unfractionated heparin in non–ST-segment–elevation myocardial infarction was a highly cost-effective strategy (incremental cost-effectiveness ratios approximately US $3100 or less). Optimal use of reperfusion therapies in eligible patients with ST-segment–elevation myocardial infarction was moderately cost effective (incremental cost-effectiveness ratio ≤$10 700). Optimal use of clopidogrel for all eligible patients with AMI or primary percutaneous coronary intervention among high-risk patients with non–ST-segment– elevation myocardial infarction in tertiary hospitals alone was less cost effective. Use of all the selected hospital-based AMI treatment strategies together would be cost-effective and reduce the total CHD mortality rate in China by ≈9.6%.
Conclusions
Optimal use of most standard hospital-based AMI treatment strategies, especially combined strategies, would be cost effective in China. However, because so many AMI deaths occur outside of the hospital in China, the overall impact on preventing CHD deaths was projected to be modest.
doi:10.1161/CIRCOUTCOMES.113.000674
PMCID: PMC4191653  PMID: 24425706
cost-benefit analysis; myocardial infarction; quality-adjusted life years; therapy
8.  Evolution in the Management of Acute Myocardial Infarction in the Autonomous Community of Valencia (Spain): Ten Years of the Primvac Registry (1995-2004) 
Introduction and objectives:
Several registries of acute myocardial infarction (AMI) have been carried out in Spain, but few remain active. This work analyses the evolution of the characteristics and control of patients with AMI during the first 10 years of the PRIMVAC registry, initiated in 1995.
Methods:
The demographical and clinical characteristics, therapeutic-diagnostic procedures and pharmacological treatment of patients admitted with AMI between January 1995 and December 2004, were analysed in 17 coronary centres in the Autonomous Community of Valencia (South eastern Spain).
Results:
The mean age of the 19,719 patients recruited was of 65. The percentage of women, hypertension, hypercholestrolemia and diabetes increased during registry period. The median time of symptoms onset-hospital arrival was 151 minutes, without a decrease over the time, and the delay of thrombolysis fell from 200 to 154 minutes (p<0.01). Percentage of thrombolytic treatment oscillated between 39% and 48%. The mortality in the coronary units decreased (14.1% vs. 8.9%; p<0.001). The number of coronary angiography and percutaneous revascularisation performed increased up to 61% and 32%, respectively, of patients included. On discharge, the use of beta-blockers (29.3% vs. 66.7%), angiotensin-converting enzyme (ACE) inhibitors (41.7% vs. 57.9%) and statins (29.3% vs. 71%) went up.
Conclusions:
Overall mortality in the coronary unit decreased, without any variation in the incidence of serious complications. Time to thrombolysis was reduced over the time, with no significant increment in its use. The performance of coronary angiography and percutaneous revascularisation increased, with a low use of primary angioplasty. The use of beta-blockers, ACE inhibitors and statins increased at discharge.
PMCID: PMC3614740  PMID: 23675181
myocardial infarction; registry; treatment; mortality
9.  Secondary prevention of ischaemic cardiac events 
BMJ Clinical Evidence  2009;2009:0206.
Introduction
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior acute myocardial infarction (MI) or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antithrombotic treatment; other drug treatments; cholesterol reduction; blood pressure reduction; non-drug treatments; and revascularisation procedures? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 154 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review. we present information relating to the effectiveness and safety of the following interventions: advice to eat less fat; advice to eat more fibre; advice to increase consumption of fish oils; amiodarone; angiotensin-converting enzyme (ACE) inhibitors; angiotensin II receptor blockers; angiotensin II receptor blockers plus ACE inhibitors; antioxidant vitamin combinations; antiplatelet agents; beta-blockers; beta-carotene; blood pressure reduction; calcium channel blockers; cardiac rehabilitation including exercise; class I antiarrhythmic agents; coronary artery bypass grafting (CABG); percutaneous coronary intervention (PCI); fibrates; hormone replacement therapy (HRT); Mediterranean diet; multivitamins; non-specific cholesterol reduction; oral anticoagulants; oral glycoprotein IIb/IIIa receptor inhibitors; psychosocial treatment; smoking cessation; statins; vitamin C; and vitamin E.
Key Points
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior MI or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Of the antithrombotic treatments, there is good evidence that aspirin (especially combined with clopidogrel in people with acute coronary syndromes or MI), clopidogrel (more effective than aspirin), and anticoagulants all effectively reduce the risk of cardiovascular events. Oral anticoagulants substantially increase the risk of haemorrhage. These risks may outweigh the benefits when combined with antiplatelet treatments. Adding oral glycoprotein IIb/IIIa receptor inhibitors to aspirin seems to increase the risk of mortality compared with aspirin alone.
Other drug treatments that reduce mortality include beta-blockers (after MI and in people with left ventricular dysfunction), ACE inhibitors (in people at high risk, after MI, or with left ventricular dysfunction), angiotensin II receptor blockers (in people with coronary artery disease), and amiodarone (in people with MI and high risk of death from cardiac arrhythmia). There is conflicting evidence on the effect of calcium channel blockers. Some types may be effective at reducing mortality in the absence of heart failure, whereas other may be harmful.Contrary to decades of large observational studies, multiple RCTs show no cardiac benefit from HRT in postmenopausal women.
Lipid-lowering treatments effectively reduce the risk of cardiovascular mortality and non-fatal cardiovascular events in people with CHD.
There is good evidence that statins reduce the risk of mortality and cardiac events in people at high risk, but the evidence is less clear for fibrates.
The magnitude of cardiovascular risk reduction in people with coronary artery disease correlates directly with the magnitude of blood pressure reduction.
Cardiac rehabilitation (including exercise), and smoking cessation all reduce the risk of cardiac events in people with CHD. Antioxidant vitamins (such as vitamin E, beta-carotene, or vitamin C) have no effect on cardiovascular events in high-risk people, and in some cases may actually increase risk of cardiac mortality.We don't know whether changing diet alters the risk of cardiac episodes, although a Mediterranean diet may have some survival benefit over a Western diet.
In selected people, such as those with more-extensive coronary disease and impaired left ventricular function, CABG may improve survival compared with an initial strategy of medical treatment. We don't know how PTCA compares with medical treatment.
We found no consistent difference in mortality or recurrent MI between CABG and PTCA with or without stenting,due to varied results among subgroups and insufficient evidence on stenting when comparing the interventions. PTCA with stenting may be more effective than PTCA alone.
PMCID: PMC2907785
10.  Use of evidence-based pharmacotherapy after myocardial infarction in Estonia 
BMC Public Health  2010;10:358.
Background
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.
Methods
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 χ2 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.
Results
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.
Conclusions
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.
doi:10.1186/1471-2458-10-358
PMCID: PMC2911401  PMID: 20569449
11.  How Medicare Part D Benefit Phases Affect Adherence with Evidence-Based Medications Following Acute Myocardial Infarction 
Health Services Research  2013;48(6 Pt 1):1960-1977.
Objective. Assess impact of Medicare Part D benefit phases on adherence with evidence-based medications after hospitalization for an acute myocardial infarction.
Data Source. Random 5 percent sample of Medicare beneficiaries.
Study Design. Difference-in-difference analysis of drug adherence by AMI patients stratified by low-income subsidy (LIS) status and benefit phase.
Data Collection/Extraction Methods. Subjects were identified with an AMI diagnosis in Medicare Part A files between April 2006 and December 2007 and followed until December 2008 or death (N = 8,900). Adherence was measured as percent of days covered (PDC) per month with four drug classes used in AMI treatment: angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), beta-blockers, statins, and clopidogrel. Monthly exposure to Part D benefit phases was calculated from flags on each Part D claim.
Principal Findings. For non-LIS enrollees, transitioning from the initial coverage phase into the Part D coverage gap was associated with statistically significant reductions in mean PDC for all four drug classes: statins (−7.8 percent), clopidogrel (−7.0 percent), beta-blockers (−5.9 percent), and ACE inhibitor/ARBs (−5.1 percent). There were no significant changes in adherence associated with transitioning from the gap to the catastrophic coverage phase.
Conclusions. As the Part D doughnut hole is gradually filled in by 2020, Medicare Part D enrollees with critical diseases such as AMI who rely heavily on brand name drugs are likely to exhibit modest increases in adherence. Those reliant on generic drugs are less likely to be affected.
doi:10.1111/1475-6773.12073
PMCID: PMC3876395  PMID: 23742013
Medicare Part D; benefit design; AMI; evidence-based drugs
12.  Quality of care of patients with acute myocardial infarction in Bulgaria: a cross-sectional study 
Background
Cardiovascular diseases are the major cause of death in Bulgaria. Because of notable differences in mortality rates between Bulgaria and other European countries, we presume a tangible difference in the management of acute myocardial infarction (AMI) and an underutilization of evidence-based treatments. In order to determine the quality of care of patients with AMI in Bulgaria, we analyzed the appropriateness of current treatments and their relation to patient characteristics.
Methods
We performed a descriptive cross-sectional study, using retrospectively collected data from medical charts. We included all patients with AMI, residing and admitted to hospitals in the region of Stara Zagora, Bulgaria, between September 1st and December 31st, 2004. Socioeconomic status was surveyed within the framework of a structured patient interview. We used chi-square tests with Fisher's exact probabilities to analyze the relationship between prehospital time delay age, sex, and socio-economic status of the patients and Student's independent samples t-tests to check hypotheses about means.
Results
From 134 patients with AMI (mean age 64.6, SD 13.2, 66% male), 7% presented to a hospital within 59 minutes, and 44% within 4 hours of symptoms onset. The use of Heparin was 98%. In the first 24 hours, ASS was administrated in 82% and β-Blockers in 73% of the cases. At discharge Aspirin, β-Blockers, Angiotensin Converting Enzyme Inhibitors or AR-Blockers and Statins were used in 85%, 79%, 66%, and 43% of cases respectively. Intravenous fibrinolysis was applied in 32% of the eligible patients with ST-segment elevation. Percutaneous coronary interventions were applied in four patients within the first month after AMI. Hospital location in relation to a patient's place of residence and manner of transportation to hospital did not influence the time delay between the onset of symptoms to the start of hospital treatment. In the study region, a relation between time delay and both age and education level was observed.
Conclusion
The actual quality of care of patients with AMI in Bulgaria lies far from the evidence-based recommendations. Additional research and improvements in health services are needed to reduce the burden of cardiovascular disease in Bulgaria.
doi:10.1186/1472-6963-9-15
PMCID: PMC2654443  PMID: 19171057
13.  Different Impact of Diabetes Mellitus on In-Hospital and 1-Year Mortality in Patients with Acute Myocardial Infarction Who Underwent Successful Percutaneous Coronary Intervention: Results from the Korean Acute Myocardial Infarction Registry 
Background/Aims
The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI).
Methods
Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM.
Results
The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191).
Conclusions
DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.
doi:10.3904/kjim.2012.27.2.180
PMCID: PMC3372802  PMID: 22707890
Diabetes mellitus; Myocardial infarction; Mortality
14.  Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries 
Aims:
Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary ‘real-world’ setting, using a methodology designed to improve the representativeness of the survey.
Methods:
Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House.
Results:
Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes.
Conclusions:
In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.
doi:10.1177/2048872613497341
PMCID: PMC3821830  PMID: 24338295
Acute myocardial infarction; Europe; hospital outcomes; survey
15.  Intensive Care Units With Low Versus High Volume of Myocardial Infarction: Clinical Outcomes, Resource Utilization, and Quality Metrics 
Background
The volume-outcome relationship associated with intensive care unit (ICU) experience with managing acute myocardial infarction (AMI) remains inadequately understood.
Methods and Results
Within a multicenter clinical ICU database, we identified patients with a primary ICU admission diagnosis of AMI between 2008 and 2010 to evaluate whether annual AMI volume of an individual ICU is associated with mortality, length-of-stay, or quality indicators. Patients were categorized into those treated in ICUs with low-annual-AMI volume (≤50th percentile, <2 AMI patients/month, n=569 patients) versus high-annual-AMI volume (≥90th percentile, ≥8 AMI patients/month, n=17 553 patients). Poisson regression and generalized estimating equation with negative binomial regression were used to calculate the relative risk (95% CI) for mortality and length-of-stay, respectively, associated with admission to a low-AMI-volume ICU. When compared with high-AMI-volume, patients admitted to low-AMI-volume ICUs had substantially more medical comorbidities, higher in-hospital mortality (11% versus 4%, P<0.001), longer hospitalizations (6.9±7.0 versus 5.0±5.0 days, P<0.001), and fewer evidence-based therapies for AMI (reperfusion therapy, antiplatelets, β-blockers, and statins). However, after adjustment for baseline patient characteristics, low-AMI-volume ICU was no longer an independent predictor of in-hospital mortality (relative risk 1.17 [0.87 to 1.56]) or hospital length-of-stay (relative risk 1.01 [0.94 to 1.08]). Similar findings were noted in secondary analyses of ICU mortality and ICU length-of-stay.
Conclusions
Admission to an ICU with lower annual AMI volume is associated with higher in-hospital mortality, longer hospitalization, and lower use of evidence-based therapies for AMI. However, the relationship between low-AMI-volume and outcomes is no longer present after accounting for the higher-risk medical comorbidities and clinical characteristics of patients admitted to these ICUs.
doi:10.1161/JAHA.114.001225
PMCID: PMC4599521  PMID: 26066030
acute myocardial infarction; intensive care unit; outcomes research; quality of care; volume-outcome relationship
16.  Medication Management Among Medicaid Myocardial Infarction Survivors 
Despite guidelines to direct appropriate medical management, the quality of care following acute myocardial infarction (AMI) may be lacking. This study characterizes medication utilization by Medicaid enrollees in the year following AMI, compares it to guidelines for secondary prevention and investigates associations with rehospitalization and survival. Using DSHS administrative claims data from Washington State, Medicaid enrollees who had an AMI in 2004 were selected. Data were de-identified and details of demographics, hospitalizations, ambulatory care, and prescriptions over the following 365 days were abstracted. Utilization of guideline-directed secondary prevention strategies was measured and associations with death and recurrent hospitalization were tested. The mortality rate was 13.4% and 38.7% were rehospitalized. Mean time to first rehospitalization was 188.6 days (SD 102.3). Prescriptions for angiotensin enzyme inhibitors or receptor blockers were initially filled by 54.0%, but year-long adherence declined to 33.3%. Beta blockers, aspirin and statins followed the same trend: 65.1% to 39.5%, 37.9% to 16.7% and 58.1% to 41.9% respectively. Twenty-two percent received all medications; 8.2% were adherent. Only the initial prescription of aspirin was significantly associated with a survival benefit (HR = 0.35, p=0.003). If the results suggested by the claims data are representative of care delivered to Medicaid enrollees, rates of application of guideline-directed medication are less than optimal. To improve survival and reduce re-hospitalization following AMI, changes in the access and delivery of healthcare could be implemented to improve medication management, both at time of discharge and over the year following AMI.
PMCID: PMC3107018  PMID: 21643550
Medicaid; Access to Care; Medication Adherence; Secondary Prevention; Cardiovascular; Myocardial Infarction; Characteristics of Care
17.  Racial/Ethnic and Gender Gaps in the Use and Adherence of Evidence-Based Preventive Therapies among Elderly Medicare Part D Beneficiaries after Acute Myocardial Infarction 
Circulation  2013;129(7):754-763.
Background
It is unclear whether gender and racial/ethnic gaps in the use of and patient adherence to β-blockers, angiotensin-converting-enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), and HMG-CoA reductase inhibitors (statins) post-acute myocardial infarction (AMI) have persisted following establishment of the Medicare Part D prescription program.
Methods and Results
This retrospective cohort study used 2007-2009 Medicare service claims among Medicare beneficiaries ≥ 65 years who were alive 30 days after an index AMI hospitalization in 2008. Multivariable logistic regression models examined racial/ethnic (white, black, Hispanic, Asian, and Other) and gender differences in the use of these therapies in the 30 days post-discharge and patient adherence at 12-months post-discharge, adjusting for patient baseline sociodemographic and clinical characteristics. Out of 85,017 individuals, 55%, 76%, and 61% used ACEIs/ARBs, β-blockers, and statins within 30 days post-discharge, respectively. No marked differences in use were found by race/ethnicity but women were less likely to use ACEI/ARBs and β-blockers compared with men. However, at 12-months post-discharge compared with white men, black and Hispanic women had the lowest likelihood (approximately 30-36% lower, p <0.05) of being adherent, followed by white, Asian, and other women and black and Hispanic men (approximately 9-27% lower, p <0.05). No significant difference was shown between Asian/other men and white men.
Conclusions
While minorities were initially no less likely to use the therapies post-AMI discharge compared with white patients, black and Hispanic patients had significantly lower adherence over 12 months. Strategies to address gender and racial/ethnic gaps in the elderly are needed.
doi:10.1161/CIRCULATIONAHA.113.002658
PMCID: PMC4351731  PMID: 24326988
Medication Adherence; Disparities; Acute Myocardial Infarction; Secondary Prevention
18.  Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study 
PLoS Medicine  2010;7(6):e1000297.
Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality.
Background
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's “Value-Based Purchasing” program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Conclusions
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
These days, many people are rewarded for working hard and efficiently by being given bonuses when they reach preset performance targets. With a rapidly aging population and rising health care costs, policy makers in many developed countries are considering ways of maximizing value for money, including rewarding health care providers when they meet targets, under “pay-for-performance.” In the UK, for example, a major pay-for-performance initiative—the Quality and Outcomes Framework—began in 2004. All the country's general practices (primary health care facilities that deal with all medical ailments) now detail their achievements in terms of numerous clinical quality indicators for common chronic conditions (for example, the regularity of blood sugar checks for people with diabetes). They are then rewarded on the basis of these results.
Why Was This Study Done?
In the US, the government is poised to implement a nationwide pay-for-performance program in hospitals within Medicare, the government program that provides health insurance to Americans aged 65 years or older, as well as people with disabilities. However, some observers are concerned about the effect that the proposed pay-for-performance program might have on the distribution of health care resources in the US. Pay-for-performance assumes that health care providers have the economic and human resources that they need to perform or to improve their performance. But, if a hospital's capacity to perform depends on local resources, payment based on performance might worsen existing health care inequalities because hospitals in under-resourced areas might lose funds to hospitals in more affluent regions. In other words, the government might act as a reverse Robin Hood, taking from the poor and giving to the rich. In this study, the researchers examine the association between hospital performance and local economic and human resources, to explore whether this scenario is a plausible result of the pending change in US hospital reimbursement.
What Did the Researchers Do and Find?
US hospitals have voluntarily reported their performance on indicators of clinical care (“process-of-care measures”) for acute myocardial infarction (AMI, heart attack), heart failure (HF), and pneumonia under the Hospital Quality Alliance (HQA) program since 2004. The researchers identified 2,705 hospitals that had fully reported process-of-care measures for AMI and HF in both 2004 and 2007. They then used the “Performance Assessment Model” (a methodology developed by the US Centers for Medicare and Medicaid Services to score hospital performance) to calculate scores for each hospital. Finally, they looked for associations between these scores and measures of the hospital's local economic and human resources such as population poverty levels and the percentage of college graduates in the workforce. Hospital performance was associated with local and economic workforce capacity, they report. Thus, hospitals in counties with longstanding poverty had lower average performance scores for HF and AMI than hospitals in affluent counties. Similarly, hospitals in counties with a low percentage of college graduates in the workforce had lower average performance scores than hospitals in counties where more of the workforce had been to college. Finally, although performance improved generally over the study period, hospitals in disadvantaged areas still lagged behind hospitals in advantaged areas in 2007.
What Do These Findings Mean?
These findings indicate that hospital performance (as measured by the clinical process measures considered here) is associated with the quantity and quality of local human and economic resources. Thus, the proposed Medicare hospital pay-for-performance program may exacerbate existing US health care inequalities by leading to the transfer of funds from hospitals in disadvantaged locations to those in advantaged locations. Although further studies are needed to confirm this conclusion, these findings have important implications for pay-for-performance programs in health care. They suggest that US policy makers may need to modify how they measure performance improvement—the current Performance Assessment Model gives hospitals that start from a low baseline less credit for improvements than those that start from a high baseline. This works against hospitals in disadvantaged locations, which start at a low baseline. Second and more generally, they suggest that there may be a tension between the efficiency goals of pay-for-performance and other equity goals of health care systems. In a world where resources vary across regions, the expectation that regions can perform equally may not be realistic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000297.
KaiserEDU.org is an online resource for learning about the US health care system. It includes educational modules on such topics as the Medicare program and efforts to improve the quality of care
The Hospital Quality Alliance provides information on the quality of care in US hospitals
Information about the UK National Health Service Quality and Outcomes Framework pay-for-performance initiative for general practice surgeries is available
doi:10.1371/journal.pmed.1000297
PMCID: PMC2893955  PMID: 20613863
19.  Secondary prevention of ischaemic cardiac events 
BMJ Clinical Evidence  2011;2011:0206.
Introduction
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior acute myocardial infarction (MI) or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures. Secondary prevention in people with an acute MI or acute coronary syndrome within the past 6 months is not included.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antithrombotic treatment; other drug treatments; cholesterol reduction; blood pressure reduction; non-drug treatments; and revascularisation procedures? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 137 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: advice to eat less fat, advice to eat more fibre, advice to increase consumption of fish oils, amiodarone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, angiotensin II receptor blockers plus ACE inhibitors, antioxidant vitamin combinations, antiplatelet agents, aspirin, beta-blockers, beta-carotene, blood pressure reduction, calcium channel blockers, cardiac rehabilitation including exercise, class I antiarrhythmic agents, coronary artery bypass grafting (CABG), fibrates, hormone replacement therapy (HRT), Mediterranean diet, multivitamins, non-specific cholesterol reduction, oral anticoagulants, oral glycoprotein IIb/IIIa receptor inhibitors, percutaneous coronary intervention (PCI), psychosocial treatment, smoking cessation, statins, vitamin C, and vitamin E.
Key Points
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior MI or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Of the antithrombotic treatments, there is good evidence that aspirin (especially combined with clopidogrel in people with acute coronary syndromes or MI), clopidogrel (more effective than aspirin), and anticoagulants all effectively reduce the risk of cardiovascular events. Oral anticoagulants substantially increase the risk of haemorrhage. These risks may outweigh the benefits when combined with antiplatelet treatments.Adding oral glycoprotein IIb/IIIa receptor inhibitors to aspirin seems to increase the risk of mortality compared with aspirin alone.
Other drug treatments that reduce mortality include beta-blockers (after MI and in people with left ventricular dysfunction), ACE inhibitors (in people at high risk, after MI, or with left ventricular dysfunction), and amiodarone (in people with MI and high risk of death from cardiac arrhythmia). There is conflicting evidence on the effect of calcium channel blockers. Some types may be effective at reducing mortality in the absence of heart failure, whereas others may be harmful.Contrary to decades of large observational studies, multiple RCTs show no cardiac benefit from HRT in postmenopausal women.
Lipid-lowering treatments effectively reduce the risk of cardiovascular mortality and non-fatal cardiovascular events in people with CHD.
There is good evidence that statins reduce the risk of mortality and cardiac events in people at high risk, but the evidence is less clear for fibrates.
The magnitude of cardiovascular risk reduction in people with coronary artery disease correlates directly with the magnitude of blood pressure reduction.
Cardiac rehabilitation (including exercise) and smoking cessation reduce the risk of cardiac events in people with CHD. Antioxidant vitamins (such as vitamin E, beta-carotene, or vitamin C) have no effect on cardiovascular events in high-risk people, and in some cases may actually increase risk of cardiac mortality.We don't know whether changing diet alters the risk of cardiac episodes, although a Mediterranean diet may have some survival benefit over a Western diet. Advice to increase fish oil consumption or fish oil consumption may be beneficial in some population groups. However, evidence was weak.Some psychological interventions may be more effective than usual care at improving some cardiovascular outcomes. However, evidence was inconsistent.
In selected people, such as those with more-extensive coronary disease and impaired left ventricular function, CABG may improve survival compared with an initial strategy of medical treatment. We don't know how PTCA compares with medical treatment.
We found no consistent difference in mortality or recurrent MI between CABG and PTCA with or without stenting, because of varied results among subgroups and insufficient evidence on stenting when comparing the interventions. CABG may be more effective than PTCA with or without stenting at reducing some composite outcomes, particularly those including repeat revascularisation rates. PTCA with stenting may be more effective than PTCA alone.
PMCID: PMC3217663  PMID: 21875445
20.  Diabetes: prevention of cardiovascular events  
BMJ Clinical Evidence  2006;2006:0601.
Introduction
Diabetes mellitus is a major risk factor for cardiovascular disease. In the USA, a survey of deaths in 1986 suggested that 60−75% of people with diabetes die from cardiovascular causes.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of promoting smoking cessation; controlling blood pressure; treating dyslipidaemia; blood glucose control; treating multiple risk factors; revascularisation procedures; and antiplatelet drugs in people with diabetes? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2004 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 63 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antihypertensive drugs, antihypertensive treatment, aspirin, clopidogrel, coronary artery bypass graft, diet, fibrates, glycaemic control (intensive versus conventional control), heparin (with or without glycoprotein IIb/IIIa inhibitors, or clopidogrel), lower target blood pressures, metformin, multiple risk factor treatment (intensive), percutaneous transluminal coronary angioplasty (plus stent), smoking cessation, statins (aggressive or moderate lipid lowering, low or standard dose), stent (plus glycoprotein IIb/IIIa inhibitors), thrombolysis.
Key Points
People with diabetes mellitus have 2−4 times the risk of cardiovascular disease, and are up to 3 times more likely to die after a myocardial infarction, compared with normoglycaemic people.
Intensive treatment of multiple risk factors in people with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular disease compared with conventional treatment. Promotion of smoking cessation is likely to reduce cardiovascular events in people with diabetes, although no studies have specifically studied this.
Tight control of blood pressure and reduction of cholesterol reduces the risk of cardiovascular events in people with hypertension and diabetes. Angiotensin converting enzyme inhibitors, angiotensin receptor antagonists, beta-blockers, calcium channel blockers and diuretics have all been shown to have similar antihypertensive effects.Reduction of cholesterol with statins reduces cardiovascular morbidity and mortality in people with diabetes regardless of initial cholesterol levels, and fibrates may also be beneficial. Aspirin and clopidogrel have not been consistently shown to reduce cardiovascular events or mortality in people with diabetes and cardiovascular disease compared with controls, and increase the risk of bleeding.Intensive blood glucose control reduces the risk of cardiovascular events in people with type 1 diabetes, but has not been consistently shown to reduce cardiovascular morbidity or mortality in people with type 2 diabetes.
Coronary artery bypass grafts reduce 4 year mortality compared with percutaneous transluminal coronary angioplasty (PTCA) in people with diabetes, although longer term benefits are unclear. PTCA may reduce short term mortality or myocardial infarction compared with thrombolysis in people with diabetes and acute myocardial infarction.Adding glycoprotein IIb/IIIa inhibitors reduces cardiovascular morbidity and mortality compared with placebo in people with acute coronary syndrome or undergoing PTCA plus stenting.
PMCID: PMC2907631
21.  Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes 
Background
Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization.
Population and methods
All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points.
Results
The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality.
Conclusions
In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.
doi:10.3978/j.issn.2223-3652.2014.02.02
PMCID: PMC3943774  PMID: 24649420
Non-ST-elevation acute coronary syndrome (NSTE-ACS); compliance; guidelines
22.  Management of acute coronary syndrome in South Africa: insights from the ACCESS (Acute Coronary Events – a Multinational Survey of Current Management Strategies) registry 
Cardiovascular Journal of Africa  2012;23(7):365-370.
Background
The burden of cardiovascular diseases is predicted to escalate in developing countries. While many studies have reported the descriptive epidemiology, practice patterns and outcomes of patients hospitalised with acute coronary syndromes (ACS), these have largely been confined to the developed nations.
Methods
In this prospective, observational registry, 12 068 adults hospitalised with a diagnosis of ACS were enrolled between January 2007 and January 2008 at 134 sites in 19 countries in Africa, Latin America and the Middle East. Data on patient characteristics, treatment and outcomes were collected.
Results
Of the 642 patients from South Africa in the registry, 615 had a confirmed ACS diagnosis and form the basis of this report; 41% had a discharge diagnosis of ST-segment elevation myocardial infarction (STEMI) and 59% a diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE-ACS), including 32% with non-ST-segment elevation myocardial infarction (NSTEMI) and 27% with unstable angina (UA).
During hospitalisation, most patients received aspirin (94%) and a lipid-lowering medication (91%); 69% received a beta-blocker, and 66% an ACE inhibitor/angiotensin receptor blocker. Thrombolytic therapy was used in only 18% of subjects (36% of STEMI patients and 5.5% of NSTE-ACS patients). Angiography was undertaken in 93% of patients (61.3% on the first day), of whom 53% had a percutaneous coronary intervention (PCI) and 14% were referred for coronary artery bypass surgery. Drug-eluting stents were used in 57.9% of cases. Clopidogrel was prescribed at discharge from hospital in 62.2% of patients.
All-cause death at 12 months was 5.7%, and was higher in patients with STEMI versus non-ST-elevation ACS (6.7 vs 5.0%, p < 0.0001). Clinical factors associated with higher risk of death at 12 months included age ≥ 70 years, presence of diabetes mellitus on admission, and a history of stroke/transient ischaemic attack (TIA).
Conclusions
In this observational study of ACS patients, the use of evidence-based pharmacological therapies for ACS was quite high. Interventional rates were high compared to international standards, and in particular the use of drug-eluting stents, yet the clinical outcomes (mortality, re-admission rates and severe bleeding episodes at one year) were favourable, with low rates compared with other studies.
doi:10.5830/CVJA-2012-017
PMCID: PMC3721828  PMID: 22447241
acute coronary syndrome; myocardial infarction; unstable angina; registry; death
23.  Optimal medical therapy for secondary prevention after an acute coronary syndrome: 18-month follow-up results at a tertiary teaching hospital in South Korea 
Background
Acute coronary syndrome (ACS) is a fatal cardiovascular disease caused by atherosclerotic plaque erosion or rupture and formation of coronary thrombus. The latest guidelines for ACS recommend the combined drug regimen, comprising aspirin, P2Y12 inhibitor, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker, β-blocker, and statin, at discharge after ACS treatment to reduce recurrent ischemic cardiovascular events. This study aimed to examine prescription patterns of secondary prevention drugs in Korean patients with ACS after hospital discharge, to access the appropriateness of secondary prevention drug therapy for ACS, and to evaluate whether to persistently use discharge medications for 18 months.
Methods
This study was retrospectively conducted with the patients who were discharged from the tertiary hospital, located in South Korea, after ACS treatment between September 2009 and August 2013. Data were collected through electronic medical record.
Results
Among 3,676 patients during the study period, 494 were selected based on inclusion and exclusion criteria. The regimen of aspirin + clopidogrel + β-blocker + angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker + statin was prescribed to 374 (75.71%) patients with ACS at discharge. Specifically, this regimen was used in 177 (69.69%) unstable angina patients, 44 (70.97%) non-ST-segment elevation myocardial infarction patients, and 153 (85.96%) ST-segment elevation myocardial infarction patients. Compared with the number of ACS patients with all five guideline-recommended drugs at discharge, the number of ACS patients using them 12 (n=169, 34.21%) and 18 (n=105, 21.26%) months after discharge tended to be gradually decreased.
Conclusion
The majority of ACS patients in this study received all five guideline-recommended medications at discharge from the hospital. However, the frequency of using all of them had been gradually decreased 3, 6, 12, and 18 months after discharge compared with that at discharge. Careful monitoring of adherence on ACS secondary prevention medications may help improve the outcomes of ACS patients in terms of recurrent ischemic cardiovascular events.
doi:10.2147/TCRM.S99869
PMCID: PMC4758787  PMID: 26929629
acute coronary syndrome; secondary prevention; guideline adherence; patient discharge; electronic medical record; cardiovascular disease
24.  A multicentre retrospective study to understand anti-platelet treatment patterns and outcomes of acute coronary syndrome patients in India (TRACE) 
Indian Heart Journal  2014;66(3):334-339.
Background
There is limited available information for treatment of acute coronary syndrome (ACS) with respect to outcomes, therapeutic agents and treatment practices. Our retrospective registry study collected and evaluated varying anti-platelet treatment strategies and outcomes of ACS patients who were admitted to 9 different tertiary care hospitals in India. This study was carried out to provide an insight to anti-platelet treatment patterns and analyze outcomes of ACS patients in India.
Methods
All the relevant data, including anti-platelet treatment strategies, outcomes and patient treatment compliance were collected from 500 ACS (defined as STEMI, NSTEMI and unstable angina [UA]) cases from January 2007 to December 2009. These ACS cases were randomly collected from the hospital records and included in the analysis. The patient follow up data was acquired either from the hospital records or via telephonic contact for a period of one year following the event.
Results
Out of 500 ACS patients, 59.8% had UA/NSTEMI and 40.2% had STEMI. On hospital admission, aspirin, clopidogrel, statins, beta-blockers and angiotensin converting enzyme inhibitors (ACE-Is) were used by 83%, 83%, 68%, 43.2% and 31.6% patients, respectively. On discharge, aspirin, clopidogrel, statins and beta-blockers were used by 90.2%, 88%, 80.6%, and 59% patients, respectively. The average patient compliance to statins, clopidogrel and aspirin was recorded as 74.28%, 69.7% and 68.66%, respectively during discharge and follow-up visits. Greater than 50% of ACS patients after discharge were lost to follow-up and as a result there was significant drop in the number of clinical events reported.
Conclusion
This pilot study conducted in tertiary care centers in India showed that patients with ACS were more often diagnosed with UA/NSTEMI as compared to STEMI and reported maximum compliance to statins, clopidogrel and aspirin after discharge over 1 year follow-up. More ACS patients were lost to follow up that resulted in low reporting of clinical outcomes, following discharge upto 1 year.
doi:10.1016/j.ihj.2014.03.009
PMCID: PMC4121748  PMID: 24973840
Acute coronary syndrome; ST-elevation myocardial infarction; Non-ST elevation myocardial infarction; Unstable angina
25.  Characteristics, In-Hospital and Long-Term Clinical Outcomes of Nonagenarian Compared with Octogenarian Acute Myocardial Infarction Patients 
Journal of Korean Medical Science  2014;29(4):527-535.
We compared clinical characteristics, management, and clinical outcomes of nonagenarian acute myocardial infarction (AMI) patients (n=270, 92.3±2.3 yr old) with octogenarian AMI patients (n=2,145, 83.5±2.7 yr old) enrolled in Korean AMI Registry (KAMIR). Nonagenarians were less likely to have hypertension, diabetes and less likely to be prescribed with beta-blockers, statins, and glycoprotein IIb/IIIa inhibitors compared with octogenarians. Although percutaneous coronary intervention (PCI) was preferred in octogenarians than nonagenarians, the success rate of PCI between the two groups was comparable. In-hospital mortality, the composite of in-hospital adverse outcomes and one year mortality were higher in nonagenarians than in octogenarians. However, the composite of the one year major adverse cardiac events (MACEs) was comparable between the two groups without differences in MI or re-PCI rate. PCI improved 1-yr mortality (adjusted hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.36-0.69, P<0.001) and MACEs (adjusted HR, 0.47; 95% CI, 0.37-0.61, P<0.001) without significant complications both in nonagenarians and octogenarians. In conclusion, nonagenarians had similar 1-yr MACEs rates despite of higher in-hospital and 1-yr mortality compared with octogenarian AMI patients. PCI in nonagenarian AMI patients was associated to better 1-yr clinical outcomes.
Graphical Abstract
doi:10.3346/jkms.2014.29.4.527
PMCID: PMC3991796  PMID: 24753700
Aged, Eighty and over; Myocardial Infarction; Percutaneous Coronary Intervention

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