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Al-Hadithy DA, Al-Maqbali JS, Al-Riyami A, Al Za'abi M, Al-Zakwani I. The Prevalence and Impact of Evidence-Based Medications on Cardiovascular and Cerebrovascular Outcomes in Patients with Acute Coronary Syndrome Post-Revascularization in Oman. PHARMACY 2023; 11:pharmacy11030079. [PMID: 37218961 DOI: 10.3390/pharmacy11030079] [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: 03/06/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/24/2023] Open
Abstract
OBJECTIVES International cardiovascular guidelines recommend prescribing a combination of five evidence-based medications (EBM) for acute coronary syndrome (ACS) patients post-revascularization. This study aims to assess the prevalence and impact of prescribing the full (five medications) versus partial (four medications or fewer) EBM combination on major adverse cardiovascular and cerebrovascular events (MACCE) in patients with ACS post-revascularization. METHODS Data from patients with ACS who had revascularization between January 2016 and September 2021 were collected retrospectively. Patients were then followed up until March 2022 for MACCE. RESULTS The full EBM combination was prescribed to 70% of the patients. However, after taking into account the presence of contraindications and clinical factors, the actual adherence to the guidelines was 95%. Patients who received the full EBM combination were younger (58 versus 62 years; p = 0.0 and 3) and had lower rates of chronic kidney disease (11% versus 41%; p < 0.001) and heart failure (9% versus 20%; p = 0.012) when compared to patients who received the partial EBM. Compared to the partial EBM group, the full EBM group was associated with lower MACCE rates (54% versus 37%, p = 0.012). After employing the propensity score technique utilizing the 1:1 nearest neighbor matching method without replacement, the univariate findings were further re-affirmed with those on full EBMs (compared to those on partial EBMs) associated with a significant reduction in the MACCE rate (average treatment effect of -25%; 95% confidence interval: -10--40%; p = 0.001). CONCLUSIONS The full EBM utilization was significantly high in our setting and in line with international guidelines. The full EBM combination was predominantly prescribed in younger and less comorbid patients and was associated with lower MACCE rates. The findings were further reaffirmed by the propensity score matching method.
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Affiliation(s)
- Dalia Ahmed Al-Hadithy
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat 123, Oman
| | - Juhaina Salim Al-Maqbali
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat 123, Oman
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
| | - Adil Al-Riyami
- Department of Medicine, Sultan Qaboos University Hospital, Muscat 123, Oman
- Oman Medical Specialty Board, Muscat 123, Oman
| | - Mohammed Al Za'abi
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat 123, Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology & Clinical Pharmacy, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat 123, Oman
- Department of Pharmacy, Sultan Qaboos University Hospital, Muscat 123, Oman
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Jomaa W, Benabdeljelil O, Chamtouri I, Abdallah W, Ben Hamda K, Maatouk F. Long-term predictors of death among Tunisian patients presenting for non ST-elevation acute coronary syndrome. LA TUNISIE MEDICALE 2022; 99:744-750. [PMID: 35261006 PMCID: PMC8796684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Coronary artery disease is the leading cause of death in emerging countries. Contemporary data about clinical profile and prognosis in Tunisian patients presenting for non ST-elevation acute coronary syndrome (NSTE-ACS) are lacking. AIM We sought to study the risk profile and 3-year mortality predictors in Tunisian patients presenting for NSTE-ACS in the contemporary setting. METHODS In this single center study, data about all consecutive patients presenting to our center for NSTE-ACS from April 2014 to July 2016 were extracted and outcomes exhaustively updated. 3-year mortality predictors were determined by multivariable survival analysis. RESULTS A total of 340 patients were included, of which 204 (61.8%) were male. Mean age was 63.6 ± 10.3 years. Prevalence of diabetes mellitus, hypertension and smoking was 57.3%, 62.4%, and 45.3%, respectively. In-hospital, 6, 12 and 36-month mortality rate was 2.3%, 3.2%, 7.1% and 15.2%, respectively. In multivariable survival analysis, independent predictors of death were age >75 (HR=5.45, 95% CI: 2.9-10.03, p<0.001), ST-segment deviation (HR=1.86, 95% CI: 1.04-3.33, p=0.036), anemia (HR=2.56, 95% CI: 1.41-4.67, p=0.002), left ventricular ejection fraction (LVEF) <40% (HR=3.5, 95% CI: 1.84-6.67, p<0.001) and a Global Registry of Acute Coronary Events (GRACE) score ≥140 (HR=2.38, 95% CI: 1.02-5.57, p=0.044). CONCLUSION In Tunisian patients presenting for NSTE-ACS, long-term mortality was high. Advanced age, ST-segment deviation, anemia, LVEF <40% and a GRACE score ≥140 were independent long-term predictors of death.
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Alsayegh F, Alkhamis MA, Ali F, Attur S, Fountain-Jones NM, Zubaid M. Anemia or other comorbidities? using machine learning to reveal deeper insights into the drivers of acute coronary syndromes in hospital admitted patients. PLoS One 2022; 17:e0262997. [PMID: 35073375 PMCID: PMC8786175 DOI: 10.1371/journal.pone.0262997] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 01/10/2022] [Indexed: 11/26/2022] Open
Abstract
Acute coronary syndromes (ACS) are a leading cause of deaths worldwide, yet the diagnosis and treatment of this group of diseases represent a significant challenge for clinicians. The epidemiology of ACS is extremely complex and the relationship between ACS and patient risk factors is typically non-linear and highly variable across patient lifespan. Here, we aim to uncover deeper insights into the factors that shape ACS outcomes in hospitals across four Arabian Gulf countries. Further, because anemia is one of the most observed comorbidities, we explored its role in the prognosis of most prevalent ACS in-hospital outcomes (mortality, heart failure, and bleeding) in the region. We used a robust multi-algorithm interpretable machine learning (ML) pipeline, and 20 relevant risk factors to fit predictive models to 4,044 patients presenting with ACS between 2012 and 2013. We found that in-hospital heart failure followed by anemia was the most important predictor of mortality. However, anemia was the first most important predictor for both in-hospital heart failure, and bleeding. For all in-hospital outcome, anemia had remarkably non-linear relationships with both ACS outcomes and patients' baseline characteristics. With minimal statistical assumptions, our ML models had reasonable predictive performance (AUCs > 0.75) and substantially outperformed commonly used statistical and risk stratification methods. Moreover, our pipeline was able to elucidate ACS risk of individual patients based on their unique risk factors. Fully interpretable ML approaches are rarely used in clinical settings, particularly in the Middle East, but have the potential to improve clinicians' prognostic efforts and guide policymakers in reducing the health and economic burdens of ACS worldwide.
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Affiliation(s)
- Faisal Alsayegh
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Moh A. Alkhamis
- Faculty of Public Health, Department of Epidemiology and Biostatistics, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Fatima Ali
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Sreeja Attur
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
| | - Nicholas M. Fountain-Jones
- School of Natural Sciences, University of Tasmania, Hobart, Australia
- Department of Veterinary Population Medicine, College of Veterinary Medicine, University of Minnesota, St. Paul, Minnesota, United States of America
| | - Mohammad Zubaid
- Faculty of Medicine, Department of Medicine, Health Sciences Center, Kuwait University, Kuwait City, Kuwait
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Rottura M, Scondotto G, Barbieri MA, Sorbara EE, Nasso C, Marino S, Scoglio R, Mandraffino G, Pallio G, Irrera N, Imbalzano E, Squadrito G, Squadrito F, Arcoraci V. Management of High Cardiovascular Risk in Diabetic Patients: Focus on Low Density Lipoprotein Cholesterol and Appropriate Drug Use in General Practice. Front Cardiovasc Med 2021; 8:749686. [PMID: 34760944 PMCID: PMC8572969 DOI: 10.3389/fcvm.2021.749686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/17/2021] [Indexed: 11/13/2022] Open
Abstract
This study aimed to evaluate the management of high cardiovascular risk (CVr) in the patients with diabetes by exploring the prescribing behavior in a setting of general practitioners (GPs). A retrospective cohort study was carried out using the data recorded between 2018 and 2020 in the clinical database of 10 GPs. Diabetes was defined using the International Classification of Diseases (ICD-9-CM) coding (250*) or using the laboratory parameters (hyperglycemia condition: ≥126 mg/dL). A cohort was described stratifying by demographic, clinical and therapeutic characteristics, and laboratory tests. Both the CVr and statin prescriptions were evaluated; adherence to statin therapy (medication possession ratio, MPR ≥ 80) was calculated in accordance with the low-density lipoprotein cholesterol (LDL-C) target. The multivariate logistic regression models with adjusted odds ratios (ORs) and the corresponding 95% Confidence Intervals (CIs) were calculated to identify the predictors of lipid modifying agents use and achieved target therapy; moreover, glucose-lowering drugs use was evaluated. Out of 13,206 people screened, 1,851 (14.0%) patients were affected by diabetes mellitus (DM), and 1,373 were identified at high/very high CVr. Of them, 1,158 (84.3%) had at least one measurement of LDL-C, and 808 (58.8%) received a prescription with at least one lipid-lowering drug (LLD). The patients at high/very high CVr treated or not treated with LLD, reached the LDL-C target in 24.0 and 10.3%, respectively (p < 0.001). Furthermore, 34.6% of patients treated with high intensity LLDs and adherent to therapy showed the LDL-C values below the therapeutic target. Out of 1,373 patients at high/very high CVr, 958 (69.8%) had at least one prescription of glucose-lowering drugs. Of them, 52.0% (n = 498) were prescribed not in agreement with the current guidelines. More specifically, 392 patients (40.9%) were treated with metformin only, while the remaining 106 (11.1%) were treated with metformin together with hypoglycemic agents other than glucagon-like peptide-1 receptor agonists (GLP1-RA) or sodium-glucose-transporter 2 (SGLT2) inhibitors. Our results suggest the urgent need to improve the management of patients with diabetes at high and very high CVr in the real life, to reduce the burden of diabetes on the health system.
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Affiliation(s)
- Michelangelo Rottura
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giulia Scondotto
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | | | | | - Chiara Nasso
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sebastiano Marino
- Italian Society of General Practice, Section Messina, Messina, Italy
| | - Riccardo Scoglio
- Italian Society of General Practice, Section Messina, Messina, Italy
| | - Giuseppe Mandraffino
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.,Internal Medicine Unit, Lipid Center, Messina, Italy
| | - Giovanni Pallio
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Natasha Irrera
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giovanni Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Squadrito
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vincenzo Arcoraci
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Al-Taweel D, Awad A. Application of MAT Methodology in the Evaluation of Prescribing Adherence to Clinical Practice Guidelines for Secondary Prevention of Coronary Heart Disease in Post-Acute Coronary Syndrome Patients in Kuwait. Front Pharmacol 2021; 12:647674. [PMID: 34671251 PMCID: PMC8520912 DOI: 10.3389/fphar.2021.647674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/23/2021] [Indexed: 11/21/2022] Open
Abstract
Quantification of prescribers’ adherence to evidence-based guidelines can be used as an outcome measure to assess the impact of services on the quality of medication use. Additionally, it can help in reducing inappropriate interventions and ensure that high-quality care is provided to patients. This study aimed to evaluate prescribing practices for secondary prevention of coronary heart disease (CHD) in post-acute coronary syndromes (ST-elevation myocardial infarction [STEMI] or non-ST elevation acute coronary syndrome [NSTEACS]) patients using two medication assessment tools (MATs) at secondary and tertiary health-care settings in Kuwait. Both MATs were developed and validated based on the relevant guidelines issued by the European Society of Cardiology and the American College of Cardiology/American Heart Association. A quantitative cross-sectional multicenter study was conducted on 460 patients’ medical records collected randomly from six health-care facilities in Kuwait. Application of MATSTEMI on 232 patients’ medication records (with 85.9% applicability) resulted in intermediate overall adherence (69.8%; 95% CI: 67.6–72.0). Application of MATNSTEACS on 228 patients’ medication records (with applicability 83.2%) resulted in intermediate overall adherence (73.3%; 95% CI: 70.5–76.0). There was no significant difference between the percentages of overall adherence among patients managed post-NSTEACS compared to those managed post-STEMI (p = 0.05). Multivariable logistic regression analysis revealed that the overall adherence to the MATSTEMI criteria was significantly higher among the specialized cardiac centers than among the general hospitals (OR: 1.6; 95% CI: 1.1–2.3; p = 0.02). The overall adherence to the MATNSTEACS criteria was found to be significantly lower among non-Kuwaitis than among Kuwaitis (OR: 0.6; 95% CI: 0.5–0.9; p = 0.01) and patients with a serum LDL ≥1.8 mmol/L than those with a serum LDL-C < 1.8 mmol/L (OR: 0.5; 95% CI: 0.4–0.7; p < 0.001). The present findings revealed that both MATs were useful tools in identifying the standard of clinical performances and highlighting areas for improvement regarding secondary prevention of CHD in post-acute coronary syndrome patients.
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Affiliation(s)
- Dalal Al-Taweel
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
| | - Abdelmoneim Awad
- Department of Pharmacy Practice, Faculty of Pharmacy, Kuwait University, Kuwait City, Kuwait
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Dewi PEN, Thavorncharoensap M. Statin Utilization among Patients with Acute Coronary Syndrome: Systematic Review. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.5807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: The early use of statin with intensive regimen has been recommended by the recent guidelines as the prevention of acute coronary syndrome (ACS) related events among the high-risk patients. Meanwhile, the inconsistent statin utilization for targeted patient in current practice is still an issue.
AIM: This study aims to review the utilization rate of statin among patients with ACS.
METHODS: A systematic search of relevant studies published between inceptions to June 2020 was conducted in PubMed. Patients and intervention domains were used to build up the searching formula. A study was eligible for inclusion if it was an original study of patients with ACS and it examined the utilization of statin. The risk of bias was assessed using Axis and NOS checklist.
RESULTS: Among the 49 eligible studies, 38 were cohort studies while the others were cross-sectional studies. The utilization rate of statin at hospital admission ranged from 16% to 61% while 25% to 75% during the hospitalization. Of the total studies, 35 studies reported the statin rate at discharge ranging from 58% to 99%. Almost all studies revealed the reduction of statin utilization rate along the follow-up period. The number of statins prescribed was found to be lower among female and elderly patients.
CONCLUSION: Despite the established benefits of statin among patients with ACS, our study revealed that statin was underutilized for secondary prevention after ACS. To improve patients’ clinical outcomes with ACS, efforts should be made to increase optimal treatment and compliance with a statin.
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Reda A, Almahmeed W, Dobrecky-Mery I, Huang PH, Juarez-Herrera U, Ranjith N, Sayre T, Urina-Triana M. A Narrative Review and Expert Panel Recommendations on Dyslipidaemia Management After Acute Coronary Syndrome in Countries Outside Western Europe and North America. Adv Ther 2020; 37:1754-1777. [PMID: 32227306 PMCID: PMC7467479 DOI: 10.1007/s12325-020-01302-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Indexed: 11/28/2022]
Abstract
Patients who have experienced an acute coronary syndrome (ACS) are at very high risk of recurrent atherosclerotic cardiovascular disease (CVD) events. Dyslipidaemia, a major risk factor for CVD, is poorly controlled post ACS in countries outside Western Europe and North America, despite the availability of effective lipid-modifying therapies (LMTs) and guidelines governing their use. Recent guideline updates recommend that low-density lipoprotein cholesterol (LDL-C), the primary target for dyslipidaemia therapy, be reduced by ≥ 50% and to < 1.4 mmol/L (55 mg/dL) in patients at very high risk of CVD, including those with ACS. The high prevalence of CVD risk factors in some regions outside Western Europe and North America confers a higher risk of CVD on patients in these countries. ACS onset is often earlier in these patients, and they may be more challenging to treat. Other barriers to effective dyslipidaemia control include low awareness of the value of intensive lipid lowering in patients with ACS, physician non-adherence to guideline recommendations, and lack of efficacy of currently used LMTs. Lack of appropriate pathways to guide follow-up of patients with ACS post discharge and poor access to intensive medications are important factors limiting dyslipidaemia therapy in many countries. Opportunities exist to improve attainment of LDL-C targets by the use of country-specific treatment algorithms to promote adherence to guideline recommendations, medical education and greater prioritisation by healthcare systems of dyslipidaemia management in very high risk patients. Video Abstract
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Affiliation(s)
- Ashraf Reda
- Department of Cardiology, Menoufia University, 127 Mohamed Fareed Street, Babellouk, Cairo, Egypt.
| | - Wael Almahmeed
- Department of Cardiovascular Medicine, Cleveland Clinic, Abu Dhabi, UAE
| | | | - Po-Hsun Huang
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | - Miguel Urina-Triana
- Cardiology Division, Faculty of Health Sciences, Simón Bolívar University, Barranquilla, Colombia
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Pejčić AV, Janković SM, Davidović G. Drug-drug interactions in patients with acute coronary syndrome across phases of treatment. Intern Emerg Med 2019; 14:411-422. [PMID: 30483990 DOI: 10.1007/s11739-018-1994-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 11/20/2018] [Indexed: 10/27/2022]
Abstract
The objective of this study is to evaluate potential drug-drug interactions (pDDIs) and risk factors for pDDIs in three phases of an acute coronary syndrome (ACS) treatment: from the point of first medical contact to the coronary angiography (first phase), after coronary angiography to the last day of hospitalization (second phase), and at discharge from hospital (third phase). This retrospective observational cohort clinical study was conducted at the Clinic for Cardiology of the Clinical Centre Kragujevac, a public tertiary care hospital in Kragujevac, Serbia. Micromedex® interaction checker was used to detect pDDIs. This study included 245 ACS patients. All patients were exposed to at least one pDDI in all the phases of treatment. Mean total number of pDDIs was 9.47 ± 6.07, 10.11 ± 6.92, and 6.29 ± 3.66 in first, second, and third phases, respectively. Age, > 6 h from the beginning of the symptoms to admission, primary PCI, STE-ACS, COPD, delirium, hyperlipidemia, hypertension, obesity, systolic blood pressure at admission, TIMI risk score at admission, ALT, LDL, number of physicians who prescribed drugs to a single patient, number of prescribed drugs, and various pharmacological classes increased risk of pDDIs. Mechanical ventilation, dementia, and drug allergy noted in the medical documentation protected against them. Effects of heart failure, diabetes, and aPTT depended on phase of treatment and severity of pDDI. In conclusion, physicians should be vigilant to the possibility of pDDIs in patients harbouring factors that may increase their rate.
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Affiliation(s)
- Ana V Pejčić
- Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia.
| | - Slobodan M Janković
- Department of Pharmacology and Toxicology, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Goran Davidović
- Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
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