• 2
    Jan
  • Use of Evidence-Based Therapy at Discharge: RESULTS

Patient Characteristics

Medical records for a total of 346 patients were reviewed. The mean age (± SD) of patients was 65.3 ± 13.4 years, and almost two-thirds (226 [65.3%]) were male (Table 2). Before admission, approximately half of the patients had dyslipidemia (181 [52.3%]) or hypertension (197 [56.9%]), and almost one-third (100 [28.9%]) had a history of acute myocardial infarction. Each medication of interest was prescribed to more than one-third of the patients at the time of admission. For the 100 patients with a history of acute myocardial infarction, the prescribing rates for the 4 medication classes at the time of admission were lower than the established benchmarks: 60.0% (60 patients) for ASA, 66.0% (66 patients) for fi-blockers, 57.0% (57 patients) for ACE inhibitors, and 50.0% (50 patients) for statins.

Table 1. Potential Exclusions for Medication Classes Noted by the Canadian Cardiovascular Outcomes Research Team/Canadian Cardiovascular Society

Medication

Exclusion Criteria


ASA


Evidence of i) active bleeding on
admission


ii) active bleeding during
hospitalization


History of i) coagulopathy or


ii) platelet count
< 100
x109/L


Allergy to ASA


Prescribed other antiplatelet agent at
discharge (e.g., ticlopidine or clopidogrel)


Physician documentation of reason for
non-use (e.g., patient refusal)


B-Blocker


Congestive heart failure
and on diuretic (unless measured left ventricular ejection fraction
>
50%)


Systolic blood pressure
<
100
mm Hg at
discharge


Severe COPD


Asthma


Bradycardia (heart rate
<
60
beats/min
at discharge)


Conduction disorder, defined as

i) first-degree
atrioventricular block (PR interval

> 0.24
s on last
ECG)

ii) second- or third-degree heart
block on last ECG

iii) bifascicular block on last ECG

Allergy or intolerance to B-blocker

Physician documentation of reason for
non-use (e.g.,symptomatic hypotension, patient refusal)

ACE inhibitors

Moderate or severe aortic stenosis

Allergy or intolerance to ACE
inhibitors

Severe renal dysfunction (peak or last pre—hospital discharge serum creatinine
> 200 ^mol/L)

Systolic BP < 100 mm Hg at discharge

Bilateral renal artery stenosis

Hyperkalemia (peak or last pre—hospital discharge K+ > 5.5 mmol/L)

Physician documentation of reason for
non-use (e.g., symptomatic hypotension)

Statins

Liver disease

Patients with cholestasis

Patients taking fibrates and at risk of rhabdomyolysis

Physician documentation of reason for non-use (e.g., patient refusal)

Prescribing Rates at Discharge for Medications of Interest

The prescribing rates for the 4 medication classes were above established benchmarks (Table 3). Most of the “ideal” patients had a discharge prescription for ASA (308 [99.0%] of 311 patients) and a fi-blocker (310 [96.3%] of 322). The rates of discharge prescribing were slightly lower for ACE inhibitors (264 [90.4%] of 292) and statins (278 [88.8%] of 313). For each medication, the number of patients for whom the drug had not been prescribed and for whom we could not locate documentation of at least one exclusion criteria or reason for nonprescribing at discharge were 3 for ASA, 12 for fi-blockers, 28 for ACE inhibitors, and 35 for statins. buy levitra 20 mg

Table 2. Characteristics of 346 Patients in a Retrospective Analysis of Therapy at Discharge after Myocardial Infarction

Characteristic

No. (%)

of Patients*


Age (years) (mean ± SD)


65.3


±
13.4


Sex, males


226 (65.3)

Discharge diagnosis


ST segment-elevation myocardial
infarction


91


(26.3)


Non-ST segment-elevation myocardial
infarction


164


(47.4)


Myocardial infarction not specified


91


(26.3)

Medical history


Cerebral vascular accident


29


(8.4)


Chronic kidney disease


28


(8.1)


Chronic obstructive pulmonary disease


42


(12.1)


Current smoker


121


(35.0)


Diabetes mellitus


99


(28.6)


Dyslipidemia


181


(52.3)


Gastrointestinal disorders


97


(28.0)


History of myocardial infarction


100


(28.9)


Hypertension


197


(56.9)


Previous percutaneous coronary
intervention


26


(7.5)


Previous coronary artery bypass graft
surgery


31


(9.0)


Medications on admission

Medications of interest


Acetylsalicylic acid


138


(39.9)


B-Blocker


137


(39.6)


Angiotensin-converting enzyme
inhibitor


142


(41.0)


Statin


120


(34.7)

Other medications


Antiarrhythmic drugs


5


(1.4)


Angiotensin receptor blocker


23


(6.6)


Calcium channel blocker


45


(13.0)


Digoxin


19


(5.5)


Diuretic


96


(27.7)


Long-acting nitrate


51


(14.7)


Warfarin


14


(4.0)


Table 3. Medication Use at Discharge among the 346 Patients

Medication

No. of Patients Ineligible*

No. of “Ideal” Patients (Total Ineligible)

No. (%) of Ideal Patients

with Prescription for Medication at Discharge

Benchmark6


ASA


35


311


308 (99.0)


> 90%


B-Blocker


24


322


310 (96.3)


> 85%


ACE inhibitor


54


292


264 (90.4)


> 85%


Statin


33


313


278 (88.8)


> 70%

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