Moving from Evidence to Practice in the Care of Patients Who Have Acute Coronary Syndrome

Take heart: a one-on-one peer-based strategy to improve acute coronary syndrome patient care

Acute coronary syndromes (ACS) result in more than 1 million hospitalizations each year in the United States and are a leading cause of morbidity and mortality. Despite evidence-based treatment guidelines and advances in therapeutic strategies, the need for well-educated practitioners to provide quality patient care is still evident. As such, continuing medical education (CME) and consultation with recognized experts are valuable tools that can enhance clinical knowledge and lead to improvements in best practices. In a CME platform, collaborative dialogue with nationally recognized opinion leaders within the field of ACS enabled 111 clinician participants to develop strategies for personal practice improvement. Faculty experts addressed specific challenging clinical questions posed by participants regarding 1 of 4 preselected topics related to the care of patients with ACS. After a 3-month period, 94% of participants reported that their strategies for practice improvement had affected patient care. Participants also rated the utility of national guidelines in their practices higher following participation in the activity and demonstrated improved clinical knowledge. As a result of this activity, participants were able to solve self-identified issues in clinical practice as well as improve their understanding of current clinical practice guidelines. Adherence to guideline-recommended care was associated with improvements in patient outcomes, and participant feedback suggests that this was an effective type of CME platform that resulted in positive changes in patient care. Furthermore, considerable interest exists for the application of this model in other therapeutic areas.

Appropriate secondary prevention of acute atherothrombotic events and strategies to improve guideline adherence

The use of guideline-recommended secondary prevention measures is essential for reducing the risk of subsequent events and mortality in patients who have survived an acute atherothrombotic event or have peripheral arterial disease. Although initial hospitalization provides an ideal environment to initiate such therapies, implementation of effective longterm prevention strategies is hindered by the absence of a systematic approach. In general, evidence-based clinical practice guidelines recommend antiplatelet therapy as a cornerstone of post-discharge secondary prevention, in addition to preventive measures targeting risk factors such as hypertension, dyslipidemia, cigarette smoking, and physical inactivity. Observational data indicate that, although there has been improvement over time, current utilization of guideline-recommended post-discharge treatment remains suboptimal. Recognizing the importance of a systematic approach to discharge planning, numerous hospital-based initiatives have been established. In conjunction with effective lines of communication between hospital and primary care teams, initiation of the most effective secondary prevention strategy at the time of hospital discharge will help to ensure optimal long-term management of patients after an atherothrombotic event.

Noninvasive, medical management for non-ST-elevation acute coronary syndromes

Despite emphasis on the use of invasive management strategies for patients with non-ST-elevation acute coronary syndromes (NSTE ACS) in recent practice guidelines, 27% to 56% of NSTE ACS patients do not undergo diagnostic angiography, and a further 45% to 78% do not undergo revascularization procedures during the initial hospitalization. These medically managed patients (also termed noninvasive management) have a greater frequency of medical comorbidities and high-risk clinical characteristics and are less likely to receive guideline-recommended medications, compared with patients who undergo revascularization procedures. The rates of short and long-term adverse outcomes are also substantially higher in medically managed NSTE ACS patients, but more widespread implementation of contemporary medical therapies in this population is limited by exclusion of medically managed patients from many randomized clinical trials.