Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq

Keywords: Acute Coronary Syndrome, Professional Practice, Guideline Adherence, Drug Utilization, Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Antagonists, Clinical Audit, Iraq


Background: Optimal prescribing of secondary prevention medications after acute coronary syndrome (ACS) events has been shown to reduce morbidity and mortality. However, it is unknown whether these medications are optimally prescribed at discharge from acute care in Iraq.

Objective: To evaluate whether patients with ACS received optimal secondary prevention medications: antiplatelets, statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs), and beta-blockers at discharge from a cardiology unit, and to assess whether statins, ACEI/ARBs and beta-blockers were prescribed at target doses based on the American Heart Association/American College of Cardiology (AHA/ACC) guidelines.

Methods: Observational retrospective cross-sectional study of patients with ACS admitted to a hospital in Baghdad and survived to discharge between May 2016 and January 2017. Patient-level data and secondary prevention medications at discharge were extracted from routine medical records. Optimal dosing was defined as ≥75%, moderate dosing as 50–74%, and low dosing as <50% of the target dose.

Results:  45.6% (200/439) of eligible patients were included in the study who were aged 25 to 90 years (mean 57.8 years) with 78.0% (156/200) being male. Of those included, 84.5% had a myocardial infarction and 15.5% unstable angina, and the length of hospital stay ranged from 1 to 29 days (median 4 days).  In total, 53.5% of patients were prescribed all five secondary prevention medications at discharge, and after accounting for contraindications, 60.0% were treated according to AHA/ACC guidelines. The prescription rate of dual antiplatelet therapy, statins, ACEI/ARBs and beta-blockers was 92.5%, 94.5%, 69.5% and 87.0% respectively. Hypertension, diabetes mellitus and the prescription of oral nitrates were associated with the prescription of optimal secondary prevention therapy. Although 80.9% of patients were prescribed target doses of antiplatelets and statins, only 12.2% and 9.2% were prescribed target doses of ACEI/ARBs, and beta-blockers respectively.

Conclusions: Approximately one in two patients received the recommended secondary prevention therapy. However, only a minority of patients were prescribed optimal doses of ACEI/ARBs and beta-blockers, in line with guidance. Quality improvement strategies should be implemented, which may include greater involvement of pharmacists within the cardiology multidisciplinary team.


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