Family Practice Vol. 20, No. 1, 32-35
© Oxford University Press 2003
Clinical Research |
Prophylactic treatment after myocardial infarction in primary care: how far can we go?
Unit of Clinical Epidemiology and Hospital/Primary Care Research Unit—Cardiology Department, Hospital General Universitari Vall d’Hebron, Pg. Vall d’Hebron, 119–129, 08035 Barcelona, Spain.
Correspondence to Carlos Brotons; E-mail: cbrotons{at}eapsardenya.net
Brotons C, Permanyer G, Pacheco V, Moral I, Ribera A, Cascant P and Pinar J, on behalf of the PREMISE study group. Prophylactic treatment after myocardial infarction in primary care: how far can we go? Family Practice 2003; 20: 32–35.
Received 17 January 2002; Revised 19 June 2002; Accepted 9 September 2002.
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Abstract |
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Background. Despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs or side effects.
Objective. Our aim was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction.
Methods. We conducted a survey of consecutive patients with a hospital diagnosis of first acute myocardial infarction during 1997 who were identified from discharge books from four hospitals and interviewed at their primary health centre 2 years after admission. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment excluding those that for one justified reason or another were off medication.
Results. Three hundred and sixty-nine patients were interviewed in the follow-up. Aspirin or another antiplatelet regimen was prescribed in 86.9 patients, ß-blockers in 50.2%, angiotensin-converting enzyme (ACE) inhibitors in 32.5% and lipid-lowering drugs in 52%. The estimated achievable standards for those prescribed drugs were 94.5, 71,8, 50.5 and 69.8%, respectively.
Conclusions. There is an underuse of prophylactic drug therapies after myocardial infarction. The standards established in this study for secondary preventive drug treatment might be achieved through a reasonable effort by GPs working in primary care committed to improving the quality of care.
Keywords. Myocardial infarction, prophylactic treatment, standards.
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Introduction |
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Patients with established coronary heart disease are one of the first priorities in cardiovascular disease prevention in primary care. Several drugs have been shown in clinical trials to reduce total and cardiovascular mortality in patients with coronary heart disease: aspirin or other antiplatelet drugs; ß-blockers in patients after acute myocardial infarction; angiotensin-converting enzyme (ACE) inhibitors in patients with symptoms or signs of heart failure at the time of myocardial infarction or persistent left ventricular systolic dysfunction; and lipid-lowering drugs to lower cholesterol concentrations to <5.0 mmol/l.
Previous studies1 have shown that there is still potential for reducing the risk of a further ischaemic event or death in patients with myocardial infarction, especially by increasing ß-blockers and lipid-lowering drugs. A recent survey carried out in 24 431 patients with coronary heart disease 2 has shown that 
36% of the patients had blood pressure >160/90 mmHg, and 45% of the patients had total cholesterol >5 mmol/l.
In addition, several strategies have been tested and performed in primary care to see if they improve the secondary preventive care of patients with coronary heart disease.3–6 Moreover, national initiatives such as the UK’s National Health Service framework for coronary heart disease7 have established as immediate priority (April 2002) to improve the use of effective medicines after heart attack, so that 80–90% of people discharged from hospital following a heart attack will be prescribed these drugs.
Nevertheless, despite best practice, it may not be achievable in some patients to reach the optimal goals of secondary prevention recommendations for various reasons, such as co-morbidity, contraindications for some drugs, side effects, etc. We do not know how far we can go in prophylactic treatments after myocardial infarction in primary care. As an example, a recent study6 found that, when comparing the effectiveness of three different interventions (audit group, general practice recall group and nurse recall group) for improving secondary preventive care, prescription of antiplatelet drugs was higher in the nurse recall group than in the other two groups, reaching a level of 85%. We do not know if this percentage could be even higher or if this is, in practice, the best result we can expect.
The aim of this study was to estimate the achievable standards for audit purposes in primary care for prophylactic treatment of secondary prevention of myocardial infarction.
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Methods |
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Consecutive patients with a hospital diagnosis of first acute myocardial infarction (AMI: ICD-9 410) during 1997 were identified from the discharge books from four hospitals (one tertiary hospital and three community hospitals) in Catalonia, Spain. Hospital records were reviewed by physicians (VP, ED, RS and BS) working at the hospital during the first semester of 1998, and information on demographic and clinical characteristics, risk factors and medication during hospitalization and at discharge was abstracted. Specifically, information about compelling or possible contraindications as well as side effects of medication during hospitalization was obtained.
Patients were contacted by telephone and interviewed at their primary health centre 2 years after the admission. Information on risk factors and medication was again recorded. Also, any information from the medical records concerning introduction or withdrawal of prophylactic treatment was recorded. We obtained the consent of individual GPs to audit medical records and interview their patients. Five GPs (ER, CF, BS, RO and SG), specially trained and employed for this project, were responsible for these tasks. In particular, they followed a common guideline that specified secondary preventive measures and contraindications for prophylactic drugs.8 If a patient was not taking one of those drugs, the GPs searched for reasons for that in medical records and also interviewed the patient. A patient was considered to be a candidate for that treatment if he or she had no contraindications for that drug or had no other medical reasons that could justify it not being used. The achievable standard for a prophylactic drug was then defined as the proportion of patients that could benefit from the treatment, excluding those that for one or other justified reason were off medication.
Descriptive data were analysed in Stata (version 5.0).
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Results |
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Six-hundred and eighteen patients with a first myocardial infarction were included in the study, 76% of whom were males, with a mean age of 64 years (range 31–97 years).
Baseline characteristics of the population in relation to recorded risk factors, and history of cardiovascular diseases and non-cardiovascular diseases are shown in Table 1
. Hypertension was the most prevalent risk factor, followed by smoking and hyperlipidaemia
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Follow-up
Four hundred and eighty-six patients (79%) were followed-up 2 years after hospitalization. Ninety patients died during the follow-up, making a total of 396 patients who were finally interviewed. Table 2
shows the prevalence of coronary risks factors at interview. More than half of the patients were overweight and had elevated total cholesterol. Table 3 provides information about prescribed treatment for secondary prevention after myocardial infarction and estimated achievable standards for each treatment according to the information obtained from hospital and primary care medical records, and also from the patient concerning adherence to treatment, contraindications and side effects. The achievable standards for antiplatelet drugs, ß-blockers, ACE inhibitors and lipid-lowering drugs were 94, 72, 50 and 70%, respectively.
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Discussion |
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The results of this study shows an underuse of prophylactic drug therapies and a high prevalence of coronary risk factors at interview in patients 2 years after they had suffered a first myocardial infarction. One of the limitations of this study is that 20% of the patients were lost to follow-up, even after having being called several times and sent several letters. Nevertheless, we compared demographic and clinical characteristics of those who were lost with those who were interviewed after 2 years of follow-up, and no statistical differences were found (data not presented). We also compared characteristics of those who died (n = 90) with those who survived to the end of the follow-up, and we found that the mean age and percentage of females was 72 years and 31%, respectively, while survivors had a mean age of 63 years and 22% were females. No other baseline clinical differences were found. The EUROASPIRE II survey study9 undertaken in 1999–2000 in 15 European countries where coronary patients were identified retrospectively also had 22% of patients lost to follow-up. This is probably one of the pitfalls of surveys where patients are identified retrospectively, and it is not easy to contact them later on.
Concerning the prevalence of risk factors at the interview, we found similar results to those observed in EUROASPIRE II (looking at the diagnostics of myocardial infarction), where it was found that 56% of the patients had elevated total cholesterol (defined as 
5 mmol/dl), 46% of the patients had raised blood pressure and 77% were overweight. Surprisingly, it was found that 26% of the patients were smokers, whereas in our study the prevalence was much lower (11%). The reason for this difference may be due to the fact that smoking status was determined in some centres of the EUROASPIRE II study using CO in breath; thus our result could be underestimated.
Concerning prophylactic treatment, aspirin or an other antiplatelet regimen was prescribed in a very high proportion of patients, and there is little to be gained. However, there is still much to gain from the use of ß-blockers, ACE inhibitors and lipid-lowering drugs, although in our previous survey in primary care we found even lower levels for those drugs.1 For instance, in 110 patients, we could find justification for not using ß-blockers (10 absolute contraindications, 82 relative contraindications, 14 side effects and in four patients it was justified by their GPs due to presenting other conditions) and in 20 patients we could find justification for not using antiplatelet drugs (six absolute contraindications, seven relative contraindications and seven side effects).
Non-compliers without either any contraindication for drugs or specific notes concerning changes in the medication in the medical record were considered as patients that potentially could gain some benefit from the treatment. A bias overestimating the standards may have occurred since clinical information was based on a retrospective review of medical records. It could be the case that specific reasons for not taking the medication or for withdrawal had not been recorded. However, this bias is very unlikely, since the GPs specially trained for this project had the opportunity to interview the patients and obtained information not recorded.
Although these standards could be a reference for audit purposes, the results of this study may not be generalizable to other health areas, and it would be desirable to replicate this study in different regions or countries. The EUROASPIRE II study revealed wide variations between countries in the use of prophylactic drugs. Four countries in particular had percentages of prescription of ß-blockers (88, 84, 77 and 74%) higher than that estimated by us as an achievable standard (72%); three countries had percentages of prescription of ACE inhibitors (59, 57 and 52%) higher than that estimated as an achievable standard (50.5%); two countries had percentages of prescription of lipid-lowering drugs (76.5 and 76%) higher than that estimated as an achievable standard (70%); and no country was found to have a higher percentage of prescription of antiplatelet drugs than that estimated as an achievable standard in our study (94.5%). These results refer to several diagnoses of coronary heart disease, thus percentages might be different if the diagnosis of myocardial infarction by country had been considered.
We believe, however, that the standards established in this study for secondary preventive drug treatment after myocardial infarction might be achieved through a reasonable effort by GPs or other health professionals working in primary care committed to improving the quality of care.
Estimating achievable standards in primary care for control of risk factors—blood pressure, total cholesterol and tobacco—should be the next step in research to complete the answer to the question of how far can we go in secondary prevention of myocardial infarction in primary care.
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Acknowledgments |
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The PREMISE Study Group: Carlos Brotons (co-ordinador), Gaietà Permanyer, Irene Moral, Aida Ribera, Purificación Cascant, Josep Pinar, Valeria Pacheco, Rosa Ortuño, Susana Gonzalez (Vall d’Hebron Hospital); Xavier Mundet, Jaume Martí (El Carmel Health Centre); Soledad Romea (Horta Health Centre); Josep Benet (Sant Andreu Health Centre); Francesc Orfila (Nou Barris Health Centre); Ramon Fito, Esteve Llargués, Elisabeth Deig y Eva Rubio (Granollers Hospital); Isabel Recasens (Granollers Health Centre); Rafael Martinez (La Garriga Health Centre); Rosario Sanjuan (Manresa Health Centre); Clotilde Farràs (Cardona Health Centre); Carmen Martinez (Bages Health Centre); Lluis Gutierrez, Beatriz Satué (Tortosa Hospital); and Carina Aguilar, Josep Mª Pepió (Baix Ebre Health Centre). This project was funded by a grant from the Agència d’Avaluació de Tecnologia i Ricerca Mèdiques (Proyect no. 01/14/98) and partly by the Ministry of Health FIS (99/1004).
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References |
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1 Brotons C, Calvo F, Cascant P, Ribera A, Moral I, Permanyer-Miralda G. Is prophylactic treatment after myocardial infarction evidence-based? Fam Pract 1998; 15:457–461.
2 Brady AJB, Oliver MA, Pittard JB. Secondary prevention in 24,431 patients with coronary heart disease: survey in primary care. Br Med J 2001; 322:1463.
3 Campbell NC, Ritchie LD, Thain J, Deans HG, Rawles JM, Squair JL. Secondary prevention in coronary heart disease: a randomised trial of nurse led clinics in primary care. Heart 1998; 80:447–452.
4 Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth A-L, Mant D, for the SHIP Collaborative group. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). Br Med J 1999; 318:706–711.
5 Feder G, Griffiths C, Eldridge S, Spence M. Effect of postal prompts to patients and general practitioners on the quality of primary care after a coronary event (POST): randomised controlled trial. Br Med J 1999; 318:1522–1526.
6 Moher M, Yudkin P, Wright L et al., for the Assessment of Implementation Strategies (ASSIST) Trial Collaborative Group. Br Med J 2001; 322:1–7.
7 Department of Health. National Health Service Framework for Coronary Heart Disease: Modern Standards and Service Models. London: HMSO, 2000.
8 Pharmacopeial Convention USP-DI. Drug Information for the Health Care Provider, 17th edn. Rockville, 1997.
9 EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries. Principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001; 22:554–572.
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