Download - Pharmacotherapy in acute coronary syndromes
Pharmacotherapy in acute coronary syndromes
Perspective from first line and regional hospitals in Czech Republic
Cardionale, 26.11.2010
Petr Jansky
Pilot MI registry (n=3188)6 non PCI hospitals
Discharge pharmacotherapy
0
10
20
30
40
50
60
70
80
90
100
2003 2004 2005 2006 2007
%
BB
ASA
statin
ACE/ARB
ticlopidin
clopidogrel
Svobodová, 2008
Jihočeský kraj:Č. Budějovice, Č. Krumlov, Prachatice, Strakonice, Písek, Tábor, Jindřichův Hradec, Dačice
Liberecký kraj:Č. Lípa, Liberec, Frýdlant, Jablonec n.N., Tanvald, Semily, Turnov, Jilemnice
All ACS patients11/2005N 1921
Widimský P. et al., Int J Cardiol, 2007
CZECH registry1/ all PCI hospitals (80%)2/ all community hospitals in two regions (20%)
Discharge pharmacotherapy STEMI
93
6682 75
848574 77
53
81
020406080
100
ASA
thie
nopyr
idin
es BB
ACEI/ARB
stat
ins
EHS ACS II 2004
CZECH registry 2005
%
Mandelzweig, EHJ, 2006 Widimský, Int J Cardiol, 2007
Discharge pharmacotherapy nonSTE ACS
84
56
83
58
7780
20
66
26
70
0
20
40
60
80
100
ASA
thie
nopyr
idin
es BB
ACEI/ARB
stat
ins
CZECH PCI centers CZECH non PCI
%
Widimský, Int J Cardiol, 2007
ESC Guidelines for the Management of NSTE-ACSESC Guidelines for the Management of NSTE-ACS
Recommendations for performance measures
Recommendations for performance measures
• Development of regional and/or national programmes to systematically measure performance indicators and provide feedback to individual hospitals is strongly encouraged (I-C).
European Heart Journal, July 2007
• Confirmed acute coronary syndromes (STEMI, NONSTEMI, unstable AP)• Continually since 1.7.2008• 32 non cath hospitals
Quality of pharmacotherapy
• Prehospital phase• Early hospital phase• On discharge
Patient characteristics 7/2008-3/2010
Mean age ± SD
n % STEMI % males males females
3995 27,5 60,6 66,8 ± 12,4 74,2 ± 11,0
Prehospital pharmacotherapy
21% 13% 3% 0% 0%6%0%
10%
20%
30%
40%
50%
ASA Clopidogrel Heparin/ LMW Heparin
BB InhibitorIIb/IIIa
Fibrinolytikum
Prehospital pharmacotherapyEMS vs physician
36% 9% 20% 3%10% 3% 6% 2%0%
10%
20%
30%
40%
50%
ASA Clopidogrel Heparin/ LMW Heparin
BB
p<0,001
p<0,001
p<0,001
Prehospital pharmacotherapy
19% 11%15% 2% 7%22%16%34% 3% 3%4% 2%0%
10%
20%
30%
40%
50%
ASA Clopidogrel Heparin/ LMW Heparin
BB
STEMI NSTEMI NAP
p<0,001
p<0,001
p<0,001
Evidence-based medical therapy (heparin, ASA, BB, statin, thienopyridin) within the first 24 hours after admission
is associated with lower in-hospital mortality in NSTEMI
18,8 18,3
16,3
7,1
4,4
2,1
0
2
4
6
8
10
12
14
16
18
20
0 1 2 3 4 5
Monhart et al., ESC 2008N 1889, p < 0,001
%
Aspirin
Linear trend: n.s.
0,8893 0,9106 0,8824 0,89250,9326
0,8837 0,9104
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
Betablockers
Linear trend: n.s.
Pharmacotherapy within 24 hours after admission
0,6455 0,6451 0,6614 0,66620,7260
0,6356 0,6132
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Clopidogrel
Linear trend: p=0,023
0,60940,6838
0,6330 0,65730,7116
0,6715 0,6840
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
Statin
Linear trend: p<0,001
0,5811
0,65340,6216
0,67280,7196
0,6647
0,7547
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
LMWH
Linear trend: n.s.
0,6045 0,6296 0,6286 0,64100,6005
0,6512 0,6321
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
Heparin
Linear trend: p=0,036
0,22290,2666 0,2647
0,2165 0,20470,1720
0,2547
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
Fondaparinux
Linear trend: p=0,011
0,17620,1225 0,1166
0,16410,2028 0,1924 0,1698
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Pharmacotherapy within 24 hours after admission
Pharmacotherapy within 24 hours after admission
* p<0,05; ** p<0,01; *** p<0,001
% Males Females <=70 y >70 y STEMI NSTEMI
Aspirin 90,8 88,4 92,7 87,4*** 92,9 89,7*
Clopidogrel 69,6 60,8** 74,2 58,9*** 77,4 65,4***
Heparin 25,8 19,6* 28,2 19,1*** 53,5 16,0***
LMWH 60,7 65,5 59,8 65,2 42,3 66,2***
BB 66,6 65,1 67,6 64,6* 52,1 67,7***
Fondaparinux 16,0 15,2 16,3 15,0 9,3 19,5***
ACEI 59,6 60,2 60,1 59,5 47,3 60,3***
Statin 66,6 64,1 70,2 61,6*** 53,8 65,6***
Aspirin
Linear trend: n.s.
0,9102 0,9359 0,9211 0,9403 0,9281 0,9222 0,9286
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Clopidogrel
Linear trend: n.s.
0,6626 0,695 0,69270,7343 0,7104
0,6570,7286
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Clopidogrel on discharge – individual hospitals
0
10
20
30
40
50
60
70
80
90
100
%
Betablockers
Linear trend: n.s.
0,8364 0,81990,857 0,8345
0,8854 0,86340,819
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Betablockers on discharge – individual hospitals
0
10
20
30
40
50
60
70
80
90
100
%
ACEI
Linear trend: p=0,012
0,76530,7311
0,815 0,819 0,8014 0,77550,823
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Statin
Linear trend: p<0,001
0,832 0,84790,8826 0,8967 0,9007 0,9038
0,9372
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Combination (aspirin, clopidogrel, BB, ACEI, statin)
Linear trend: p=0,010
0,4283 0,42050,4707
0,5164 0,51940,4415
0,4854
0%
20%
40%
60%
80%
100%
2008 III 2008 IV 2009 I 2009 II 2009 III 2009 IV 2010 I
Discharge pharmacotherapy
Discharge pharmacotherapy
% Males Females <=70 y >70 y STEMI NSTEMI
Aspirin 93,5 91,6 95,6 89,9*** 96,6 92,5***
Clopidogrel 74,2 62,9*** 78,5 60,9*** 87,3 71,6***
BB 85,2 83,4 86,0 83,0* 86,1 84,0
ACEI 79,8 77,6 79,9 78,1 82,3 77,0**
Statin 89,7 85,4 92,3 83,6*** 91,4 85,7**
* p<0,05; ** p<0,01; *** p<0,001
Conclusion
• Unsatisfactory prehospital pharmacotherapy • In-hospital pharmacotherapy is relatively good
(exc. elderly, females, NONSTEMI)• Interhospital variability in the quality of care• Improvement in some recommended therapies
(statins, clopidogrel in the acute phase) over short time period
Thank you for your attention !