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 !