Year : 2009 | Volume
: 10 | Issue : 1 | Page : 6--10
The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race)
Abdullah Al Shukry, Wafa Rashed, Mohammad Zubaid
Department of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait
Backgrounds: The use of certain medications in acute myocardial infarction (AMI) is known to lower morbidity and mortality. We aimed to evaluate, through the use of performance measures, the implementation of specific guidelines-recommended pharmacotherapy in the management of AMI in patients living in the Arabian Peninsula.
Materials and Methods: The Gulf Registry of Acute Coronary Events (Gulf RACE) enrolled ACS patients from 6 countries in the Arabian Peninsula. We examined the use of 7 performance measures that relate to the management of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).
Results: 5833 AMI patients were enrolled in Gulf RACE. In the first 24 hours of hospital arrival, 5713 (98%) patients were administered aspirin. The prescription rate at discharge was 5376 (97%) for aspirin, 4354 (78%) for beta-blockers, 5639 (84%) for statins and 3145 (57%) for clopidogrel. Left ventricular systolic function (LVSF) was evaluated in 3861 (66%) patients. Of those who had ejection fraction < 40% (921 patients), 725 (85%) received angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at discharge.
Conclusion: There was good adherence to guidelines-recommended medications in patients admitted to hospital with a diagnosis of AMI. The implementation of more performance measures need to be evaluated in order to assess the full picture of AMI management in this part of the world.
|How to cite this article:|
Al Shukry A, Rashed W, Zubaid M. The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race).Heart Views 2009;10:6-10
|How to cite this URL:|
Al Shukry A, Rashed W, Zubaid M. The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race). Heart Views [serial online] 2009 [cited 2019 Dec 13 ];10:6-10
Available from: http://www.heartviews.org/text.asp?2009/10/1/6/63833
According to the World Health Organization (WHO), cardiovascular disease is estimated to become the leading cause of death in developing countries by 2010  . Therefore, the incidence of acute myocardial infarction (AMI) in the Middle East is expected to rise. For those who survive an initial AMI, the risk of further cardiovascular problems, including recurrent myocardial infarction, sudden cardiac death, heart failure, and stroke is substantial , . Studies have shown that advances in cardiovascular care over the past years have reduced mortality and morbidity associated with AMI  , however there still remains a gap between the care delivered and that which ought to be delivered to these patients , . Guidelines for the management of different cardiovascular diseases, including AMI have been developed to bridge this gap , . The American Heart Association (AHA) and the American College of Cardiology (ACC) have developed a list of specific performance measures that can be evaluated in the management of AMI  . The degree of implementation of these performance measures in any institution reflects the quality of care at that institution.
In this study, we evaluate specific aspects of the quality of care provided to AMI patients enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE), through the assessment of the implementation of some of the performance measures recommended by the AHA/ACC. The purpose of this effort is to allow practitioners and institutions in the Arabian Gulf to measure and assess the quality of their medical care and to enable visualization of specific areas requiring improvement.
Gulf RACE is a Gulf Heart Association (GHA) project. It was a 6-month prospective, observational study of consecutive ACS patients recruited from 64 hospitals in 6 Middle Eastern countries. The 6 participating countries were Bahrain, Kuwait, Qatar, Oman, United Arab Emirates (UAE) and Yemen. The study received ethical approval from the institutional ethical bodies in all participating countries. In Bahrain, Kuwait and Qatar, all hospitals nationwide that admit patients with ACS participated in the survey. In Oman, UAE and Yemen, most hospitals (covering at least 85% of the population) participated in the survey. Full details of the methods have been published previously  . Briefly, patients' data were collected using standardized case report form (CRF). These included patients' demographics, past medical history, provisional diagnosis on admission and discharge, clinical features at hospital presentation, ECG findings, laboratory investigations, early in-hospital medications (administered within 24 hours of admission), discharge medications, use of cardiac procedures and interventions, in-hospital outcomes and in-hospital mortality. The management of AMI patients in Gulf RACE was left to the discretion of the treating physician. Recruitment in the pilot phase started on May 8, 2006 for 30 days. Enrolment in the next phase of the registry started on January 29, 2007 and continued for 5 months. We report on patients with AMI recruited during the entire 6 months of the registry.
In this report, we evaluated the performance of the enrolling hospitals in relation to the use of seven specific evidence-based measures derived from the AHA and ACC performance measures for the management of STEMI and NSTEMI  . These performance measures were the following: use of aspirin within 24 hours of hospital arrival; evaluation of left ventricular systolic function (LVSF) during hospitalization or planning it after discharge; use of angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in patients with left ventricular ejection fraction (LVEF) less than 40%; prescription of aspirin at hospital discharge; prescription of a beta-blocker at hospital discharge; prescription of a statin at hospital discharge; prescription of clopidogrel at hospital discharge.
Baseline and clinical characteristics of patients were presented as frequencies and means. All data analyses were carried out using the Statistical Package for Social Sciences version 14 (SPSS Inc. USA).
5833 patients with the final diagnosis of AMI were recruited in Gulf RACE. 3096 (53%) patients were diagnosed with ST-segment elevation myocardial infarction (STEMI), 106 (2%) patients were diagnosed with left bundle branch block myocardial infarction (LBBBMI) and 2631 (45%) were diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). The mean age in this cohort was 56.6±12.4 years. 4738 (81%) were males and 1095 (19%) were females [Table 1]. Risk factors for coronary artery disease were common among patients, with 2280 (39%) patients suffering from diabetes and 2437 (42%) were active smokers. The recruitment per country is shown in [Figure 1].
Evaluation of Performance Measures
Of 5833 patients admitted with AMI, aspirin was administered to 5713 (98%) patients within 24 hours of hospital arrival [Table 2]. At hospital discharge, 5376 (97%) patients were prescribed aspirin, 4354 (78%) patients were prescribed a beta-blocker, 4639 (48%) were prescribed a statin and 3145 (57%) of patients were prescribed clopidogrel. 3861 (66%) patients underwent evaluation of LVSF by either echocardiography or coronary angiography, of whom 921 had LVEF , . A comparison between our performance and other registries is shown in [Table 3].
Guidelines strongly recommend the early administration of aspirin to patients hospitalized with AMI and the continued use of aspirin at discharge  . Ninety eight percent of our patients were administered aspirin within 24 hours of hospital arrival and 97% were prescribed it at hospital discharge. The long-term use of beta-blocker therapy for the secondary prevention of cardiovascular events after AMI is strongly recommended by guidelines  . In Gulf RACE, 78% of our AMI patients were prescribed beta-blocker therapy at hospital discharge. Another performance measure we looked at was the prescription of a statin to patients at hospital discharge. There is unequivocal evidence supporting the use of statin therapy in patients who have suffered AMI. In Gulf RACE, 84% of our AMI patients were prescribed a statin at hospital discharge. Data on the benefits of combined anti-platelet therapy with clopidogrel and aspirin for ACS patients has been consistently increasing over the years  , and its efficacy has been proven by several trials ,,,,, . In Gulf RACE, 57% of our medically-treated AMI patients were prescribed clopidogrel at hospital discharge. We found that the implementation of the above 5 mentioned performance measures was well comparable to other ACS registries, namely the Euro Heart Survey of Acute Coronary Syndromes II (EHS-ACS-II) and the National Registry of Myocardial Infarctions (NRMI-5).
LVSF is an important prognostic indicator for patients with AMI  . After a myocardial infarction, about 50% of patients develop asymptomatic left ventricular systolic dysfunction (LVSD)  . Due to the lack of signs and symptoms of heart failure, a false sense of well-being may be created, depriving patients of vital treatments. Therefore, assessment of LVSF is essential  . Sixty six percent of AMI patients in Gulf RACE underwent LVSF evaluation through either echocardiography or coronary angiography. According to the AHA/ACC performance measures, AMI patients with LVSD and without contraindications should be prescribed an ACEI or ARB at hospital discharge. LVSD is defined as chart documentation of LVEF less than 40% or a narrative description of LVSF consistent with moderate or severe systolic dysfunction  . Eighty five percent of our AMI patients whose LVEF was less than 40% were prescribed ACEI or ARB therapy at hospital discharge.
The conclusions drawn from this evaluation are reassuring. Medical practitioners in the Gulf have implemented the selected performance measures in an effective manner. The implementation of these specific performance measures in Gulf RACE was comparable to their implementation in well-known AMI registries. On this basis, medical institutions that provide care for AMI patients must maintain this quality of care by undergoing continuing audits and feed back to clinicians with regards to their adherence to the AHA/ACC performance measures. Additionally, clinicians who look after AMI patients must be encouraged to strictly adhere to these performance measures and to clearly document the rationale behind omitting or not adhering to certain measures. Collectively, these efforts will allow hospitals to maintain high standards in the management of AMI patients.
One of the major limitations was that patient details were documented in Gulf RACE in the form of CRFs which did not include the reasoning behind the omission of certain medications or investigations. Therefore, reasons why certain medications were not administered or prescribed to eligible patients were not explored. Another limitation was the lack of knowledge about the estimated number of patients who would not be able to consume the recommended medications. This has led to the comparison with western registries, which might have not been accurately representative of standards that one should expect to meet in local hospitals.
We would like to thank sanofi aventis-Gulf and Qatar Telecommunications Company for their funding of the registry. Special thanks to Miss Rihab Moneer for her help in the preparation of this manuscript.
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