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Suki SZ, Zuhdi ASM, Yahya A, Adnan WAHWM, Zaharan NL. Prescribing Trends of Renin-Angiotensin System Inhibitors and Mortality among Acute Coronary Syndrome Patients: Insights from the Malaysian National Cardiovascular Disease Registry. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2024; 12:145-152. [PMID: 38764563 PMCID: PMC11098274 DOI: 10.4103/sjmms.sjmms_422_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/10/2024] [Accepted: 02/07/2024] [Indexed: 05/21/2024]
Abstract
Background Despite guideline recommendations, suboptimal prescription rates of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) have been observed in patients with acute coronary syndrome. Objective This study aimed to examine the temporal trends, variations, and mortality outcomes among acute coronary syndrome patients prescribed ACEIs/ARBs in the multi-ethnic population of Malaysia. Methodology This retrospective study utilized data from the Malaysian National Cardiovascular Disease-Acute Coronary Syndrome registry, encompassing consecutive patient records from 2008 to 2017 (N = 60,854). Ten-year temporal trends of on-discharge ACEIs/ARBs prescription were examined. Demographics, clinical characteristics and 1-year all-cause mortality outcomes were compared between patients prescribed and not prescribed ACEIs/ARBs. Results The 10-year prescription rate of on-discharge ACEIs/ARBs was 52.8% (n = 32,140), with a significant decline over the years [linear trend test, P = 0.008; SD = 0.03; SE = 0.001; 95% CI = 0.55-0.64]. Patients aged ≥65 years (aOR = 0.79; 95% CI = 0.73-0.86) were less likely to be prescribed ACEIs/ARBs than those aged <65 years. In addition, patients with comorbid diabetes mellitus (DM) (aOR = 0.85; 95% CI = 0.79-0.92) and chronic kidney disease (CKD) (aOR = 0.34; 95% CI = 0.30-0.40) were significantly less likely to receive ACEIs/ARBs. IPW-adjusted survival analysis revealed a 38% lower 1-year all-cause mortality rate in patients prescribed on-discharge ACEIs/ARBs (HR = 0.62; 95% CI = 0.56-0.69; P < 0.001). Conclusion Acute coronary syndrome patients with concomitant DM and CKD were less likely to receive on-discharge ACEIs/ARBs in Malaysia. Suboptimal prescription rates of ACEIs/ARBs persisted over the 10-year period, despite improved 1-year survival in ACS patients prescribed ACEIs/ARBs.
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Affiliation(s)
- Siti Zaleha Suki
- Department of Pharmacology, Faculty of Dentistry, Universiti Teknologi MARA, Selangor, Malaysia
- Centre of Preclinical Science Studies, Faculty of Dentistry, Universiti Teknologi MARA, Selangor, Malaysia
| | | | - Abqariyah Yahya
- Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Selangor, Malaysia
| | - Wan Ahmad Hafiz Wan Md Adnan
- Department of Medicine, Division of Nephrology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Nur Lisa Zaharan
- Department of Pharmacology, Faculty of Dentistry, Universiti Teknologi MARA, Selangor, Malaysia
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Tern PJW, Vaswani A, Yeo KK. Identifying and Solving Gaps in Pre- and In-Hospital Acute Myocardial Infarction Care in Asia-Pacific Countries. Korean Circ J 2023; 53:594-605. [PMID: 37653695 PMCID: PMC10475691 DOI: 10.4070/kcj.2023.0169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 06/25/2023] [Indexed: 09/02/2023] Open
Abstract
Acute myocardial infarction (AMI) is a major cause of morbidity and mortality in the Asia-Pacific region, and mortality rates differ between countries in the region. Systems of care have been shown to play a major role in determining AMI outcomes, and this review aims to highlight pre-hospital and in-hospital system deficiencies and suggest possible improvements to enhance quality of care, focusing on Korea, Japan, Singapore and Malaysia as representative countries. Time to first medical contact can be shortened by improving patient awareness of AMI symptoms and the need to activate emergency medical services (EMS), as well as by developing robust, well-coordinated and centralized EMS systems. Additionally, performing and transmitting pre-hospital electrocardiograms, algorithmically identifying patients with high risk AMI and developing hospital networks that appropriately divert such patients to percutaneous coronary intervention-capable hospitals have been shown to be beneficial. Within the hospital environment, developing and following clinical practice guidelines ensures that treatment plans can be standardised, whilst integrated care pathways can aid in coordinating care within the healthcare institution and can guide care even after discharge. Prescription of guideline directed medical therapy for secondary prevention and patient compliance to medications can be further optimised. Finally, the authors advocate for the establishment of more regional, national and international AMI registries for the formal collection of data to facilitate audit and clinical improvement.
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Affiliation(s)
- Paul Jie Wen Tern
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Amar Vaswani
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Khung Keong Yeo
- Department of Cardiology, National Heart Centre Singapore, Singapore.
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Hofmann B. Ethical issues with geographical variations in the provision of health care services. BMC Med Ethics 2022; 23:127. [PMID: 36474244 PMCID: PMC9724375 DOI: 10.1186/s12910-022-00869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 11/26/2022] [Indexed: 12/12/2022] Open
Abstract
Geographical variations are documented for a wide range of health care services. As many such variations cannot be explained by demographical or epidemiological differences, they are problematic with respect to distributive justice, quality of care, and health policy. Despite much attention, geographical variations prevail. One reason for this can be that the ethical issues of geographical variations are rarely addressed explicitly. Accordingly, the objective of this article is to analyse the ethical aspects of geographical variations in the provision of health services. Applying a principlist approach the article identifies and addresses four specific ethical issues: injustice, harm, lack of beneficence, and paternalism. Then it investigates the normative leap from the description of geographical variations to the prescription of right care. Lastly, the article argues that professional approaches such as developing guidelines, checklists, appropriateness criteria, and standards of care are important measures when addressing geographical variations, but that such efforts should be accompanied and supported by ethical analysis. Hence, geographical variations are not only a healthcare provision, management, or a policy making problem, but an ethical one. Addressing the ethical issues with geographical variations is key for handling this crucial problem in the provision of health services.
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Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU), PO Box 191, 2801, Gjøvik, Norway.
- The Centre for Medical Ethics, University of Oslo, PO Box 1130, 0318, Oslo, Norway.
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Suki SZ, Zuhdi ASM, Yahya 'AA, Zaharan NL. Intervention and in-hospital pharmacoterapies in octogenarian with acute coronary syndrome: a 10-year retrospective analysis of the Malaysian National Cardiovascular Database (NCVD) registry. BMC Geriatr 2022; 22:23. [PMID: 34983393 PMCID: PMC8729007 DOI: 10.1186/s12877-021-02724-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 12/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Octogenarians and beyond have often been neglected in the populational study of disease despite being at the highest point of non-modifiable disease risk burden and the fastest-growing age group for the past decade. This study examined the characteristics and in-hospital management of octogenarian patients with acute coronary syndrome (ACS) in a multi-ethnic, middle-income country in South East Asia. METHOD This retrospective study utilised the Malaysian National Cardiovascular Disease- ACS (NCVD-ACS) registry. Consecutive patient data of those ≥80 years old admitted with ACS at 24 participating hospitals from 2008 to 2017 (n = 3162) were identified. Demographics, in-hospital intervention, and evidence-based pharmacotherapies over the 10-years were examined and compared across groups of interests using the Chi-square test. Multivariate logistic regression was used to calculate the adjusted odds ratio of receiving individual therapies according to patients' characteristics. RESULTS Octogenarians made up 3.8% of patients with ACS in the NCVD-ACS registry (mean age = 84, SD ± 3.6) from 2008 until 2017. The largest ethnic group was Chinese (44%). Most octogenarians (95%) have multiple cardiovascular risk factors, with hypertension (82%) being the main. Non-ST-elevation myocardial infarction (NSTEMI) predominated (38%, p < 0.001). Within the 10-year, there were positive increments in cardiovascular intervention and pharmacotherapies. Only 10% of octogenarians with ACS underwent percutaneous coronary intervention (PCI), the majority being STEMI patients (17.5%; p < 0.05). More than 80% were prescribed aspirin (91.3%) either alone or combined, dual antiplatelet therapy (DAPT) (83.3%), anticoagulants (89.7%) and statins (89.6%), while less being prescribed angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (47.6%) and beta-blockers (43.0%). Men were more likely to receive PCI than women (adjusted Odds Ratio (aOR): 0.698; 95% CI: 0.490-0.993). NSTEMI (aOR = 0.402, 95% CI: 0.278-0.583) and unstable angina (UA) (aOR = 0.229, 95% CI: 0.143-0.366) were less likely to receive PCI but more likely given anticoagulants (NSTEMI, aOR = 1.543, 95% CI: 1.111-2.142; UA, aOR = 1.610, 95% CI: 1.120-2.314) than STEMI. The presence of cardiovascular risk factors and comorbidities influences management. CONCLUSION Octogenarians with ACS in this country were mainly treated with cardiovascular pharmacotherapies. As the number of octogenarians with ACS will continue to increase, the country needs to embrace the increasing use of PCI in this group of patients.
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Affiliation(s)
- Siti Z Suki
- Department of Pharmacology, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Ahmad S M Zuhdi
- Cardiology Unit, Department of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - ' Abqariyah A Yahya
- Department of Social and Preventive Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Nur L Zaharan
- Department of Pharmacology, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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Lopez D, Nedkoff L, Briffa T, Preen DB, Etherton-Beer C, Flicker L, Sanfilippo FM. Effect of frailty on initiation of statins following incident acute coronary syndromes in patients aged ≥75 years. Maturitas 2021; 153:13-18. [PMID: 34654523 DOI: 10.1016/j.maturitas.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 07/12/2021] [Accepted: 07/13/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Statin use for preventing recurrent acute coronary syndromes (ACS) is low in older people due to many clinical factors, including frailty. Using the recently developed hospital frailty risk score, which allows ascertainment of frailty from real-world data, we examined the association between frailty and initiation of statin treatment following incident ACS in patients aged ≥75 years. Our secondary aim was to determine whether non-initiation of statins was associated with more conservative treatment, defined as non-receipt of evidence-based medicines and/or coronary artery procedures. METHODS We used person-linked hospital administrative and Pharmaceutical Benefits Scheme data to identify incident ACS admissions between 2005 and 2008 in Western Australia and prescription medicine use, respectively. Outcomes were receipt of any statin, high-dose statin, beta-blockers, renin-angiotensin system inhibitors (RASI), antiplatelets and coronary artery procedures within six months of the incident ACS and were analysed using multivariable generalised linear regression models. RESULTS In 1,558 patients (52.4% female, mean age 82.6 years), initiation of any statin or high-dose statin decreased with increasing frailty. The adjusted risk ratios for any statin were 0.89 (95% CI: 0.82-0.97) and 0.67 (95% CI: 0.54-0.85) for the intermediate- and high-frailty categories compared with the low-frailty category, respectively. Compared with patients who received statins, those not receiving statins were less likely (p<0.001) to receive beta-blockers (80.8% vs 51.5%), RASI (86.9% vs 62.1%), antiplatelets (90.9% vs 65.1%) or a coronary artery procedure (65.9% vs 21.1%). CONCLUSIONS Increasing frailty is inversely associated with initiation of statins and generally leads to a more conservative approach to treatment of older patients with ACS.
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Affiliation(s)
- Derrick Lopez
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia.
| | - Lee Nedkoff
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - David B Preen
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Christopher Etherton-Beer
- Western Australian Centre for Health and Ageing, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Leon Flicker
- Western Australian Centre for Health and Ageing, Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Frank M Sanfilippo
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
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Venkatason P, Zubairi YZ, Zaharan NL, Wan Ahmad WA, Hafidz MI, Ismail MD, Hadi MF, Md Sari N, Zuhdi ASM. Characteristics and short-term outcomes of young women with acute myocardial infarction in Malaysia: a retrospective analysis from the Malaysian National Cardiovascular Database registry. BMJ Open 2019; 9:e030159. [PMID: 31748289 PMCID: PMC6886979 DOI: 10.1136/bmjopen-2019-030159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Young women form a minority but an important group of patients with acute myocardial infarction (MI) as it can potentially cause devastating physical and socioeconomic impact. This study was aimed to investigate the characteristics and outcomes of young women with MI in Malaysia. DESIGN This is a retrospective analysis of women with ST-elevation MI (STEMI) and non-STEMI (NSTEMI) from 18 hospitals across Malaysia using the Malaysian National Cardiovascular Database registry-acute coronary syndrome (NCVD-ACS). PARTICIPANTS Women patients diagnosed with acute MI from year 2006 to 2013 were identified and divided into young (age ≤ 45, n=292) and older women (age >45, n=5580). PRIMARY OUTCOME MEASURE Comparison of demographics, clinical characteristics and in-hospital management was performed between young and older women. In-hospital and 30-day all-cause mortality were examined. RESULTS Young women (mean age 39±4.68) made up 5% of women with MI and were predominantly of Malay ethnicities (53.8%). They have a higher tendency to present as STEMI compared with older women. Young women have significantly higher rates of family history of premature coronary artery disease (CAD) (20.5% vs 7.8% p<0.0001). The prevalence of risk factors, such as hypertension, diabetes and dyslipidaemia was high in both groups. The primary reperfusion strategy was thrombolysis with no significant differences observed in the choice of intervention for both groups. Other than aspirin, rates of prescriptions for evidence-based medications were similar with >80% prescribed statins and aspirin. The all-cause mortality rates of young women were lower for both in-hospital and 30 days, especially in those with STEMI with adjusted mortality ratio to the older group, was 1:9.84. CONCLUSION Young women with MI were over-represented by Malays and those with a family history of premature CAD. Preventive measures are needed to reduce cardiovascular risks in young women. Although in-hospital management was similar, short-term mortality outcomes favoured young compared with older women.
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Affiliation(s)
- Padmaa Venkatason
- Department of Medicine, University of Malaya Faculty of Medicine, Kuala Lumpur, Malaysia
| | - Yong Z Zubairi
- Foundation Studies in Science, Universiti Malaya, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Nur Lisa Zaharan
- Department of Pharmacology, University of Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan, Malaysia
| | - Wan Azman Wan Ahmad
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Imran Hafidz
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Muhammad Dzafir Ismail
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mohd Firdaus Hadi
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Norashikin Md Sari
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Ahmad Syadi Mahmood Zuhdi
- Cardiology Unit, Department of Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
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Ahrens I, Averkov O, Zúñiga EC, Fong AYY, Alhabib KF, Halvorsen S, Abdul Kader MABSK, Sanz‐Ruiz R, Welsh R, Yan H, Aylward P. Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox. Clin Cardiol 2019; 42:1028-1040. [PMID: 31317575 PMCID: PMC6788484 DOI: 10.1002/clc.23232] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/27/2019] [Accepted: 07/06/2019] [Indexed: 12/14/2022] Open
Abstract
Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.
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Affiliation(s)
- Ingo Ahrens
- Augustinerinnen Hospital, Academic Teaching HospitalUniversity of CologneCologneGermany
| | - Oleg Averkov
- Pirogov Russian National Research Medical UniversityMoscowRussia
| | | | - Alan Y. Y. Fong
- Department of CardiologySarawak Heart CentreKota SamarahanMalaysia
| | - Khalid F. Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac CentreCollege of Medicine, King Saud UniversityRiyadhSaudi Arabia
| | | | | | | | - Robert Welsh
- Mazankowski Alberta Heart Institute and University of AlbertaEdmontonAlbertaCanada
| | | | - Philip Aylward
- South Australian Health and Medical Research InstituteFlinders University and Medical CentreAdelaideAustralia
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