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Guideline adherence for antithrombotic therapy in acute coronary syndrome: an overview in Dutch hospitals

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Abstract

Objective. To assess current Dutch antithrombotic treatment strategies for acute coronary syndrome (ACS) in light of the current European Society of Cardiology (ESC) guidelines.

Methods. For every Dutch hospital with a coronary care unit (CCU) (n = 93) a single cardiologist was interviewed concerning heparin, thienopyridine and GP IIb/IIIa inhibitor (GPI) treatment. In each hospital, we randomly approached one cardiologist assuming equal policy among physicians employed at the same hospital.

Results. The response rate was 90%. In 59% of hospitals, treatment of ST-elevation myocardial infarction (STEMI) occurred according to the 2008 ESC STEMI guideline, with unfractionated heparin. In contrast, although not recommended, low-molecular-weight heparin (LMWH) was used in 39% (enoxaparin 19%, dalteparin 12%, nadroparin 8%). In non-STEMI, low-molecular-weight-heparins (LMWHs) were used in 97% of all hospitals. Fondaparinux, agent of choice in a noninvasive strategy for the treatment of non-STEMI, was applied in only 2% of hospitals. Although recommended by the ESC, dose adjustment of LMWH therapy for patients with renal failure is not applied in 71% of hospitals. Likewise, LMWH dose adjustment is not applied for patients aged over 75 years in 92% of hospitals.

Conclusion. To a great extent treatment of ACS in the Netherlands occurs according to ESC guidelines. Additional benefit may be achieved by routine dose adjustment of LMWH for patients with renal insufficiency and aged >75 years, since these patients are at high risk of bleeding complications secondary to antithrombotic treatment. Periodical evaluation of real-life practice may improve guideline adherence and potentially improve clinical outcome. (Neth Heart J 2010;18:291-9.)

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Authors and Affiliations

  1. Department of Cardiology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100, DD, Amsterdam, the Netherlands

    W. J. Kikkert

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    W. J. Kikkert

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  1. W. J. Kikkert
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  2. J. J. Piek
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  3. R. J. de Winter
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Appendix. Questionnaire

Appendix. Questionnaire

Antithrombotic treatment for patients with Acute Coronary Syndrome

Please answer the questions for practice applied in your hospital/institution.

For all hospitals

1. Which anticoagulant agent is administered to patients with acute ST-elevation myocardial infarction (STEMI) in your hospital regardless of type of reperfusion therapy (e.g. unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), bivalirudin or fondaparinux)?

2. Which anticoagulant dose regimen is applied in STEMI patients treated with primary Percutaneous Coronary Intervention (PCI)?

3. Which anticoagulant agent is administered to patients with acute non-ST-elevation myocardial infarction or unstable angina (UA/NSTEMI) in your hospital regardless of reperfusion therapy (e.g. UFH, LMWH, bivalirudin or fondaparinux)?

4. Which loading dose for clopidogrel is applied in your institution in STEMI and UA/NSTEMI?

5. Is routine dose-adjustment of antithrombotic regimen applied for patients with renal insufficiency?

6. Is routine dose-adjustment of antithrombotic regimen applied for patients aged 75 or older?

For hospitals equipped with PCI facilities:

7. Which GPI is administered in your institution?

8. What are the indications for GPI therapy in STEMI patients?

9. How many STEMI patients do you estimate are treated with GPI within your department?

10. What are the indications for GPI therapy in patients with UA/NSTEMI?

11. How many NSTE-ACS patients do you estimate are treated with GPI within your department?

12. Is GPI combined with anticoagulant therapy such as heparin? What is the administered dosage of this anticoagulant agent?

For ambulance services:

13. Is thrombolysis applied on your ambulance service for STEMI patients? (yes/no)

14. Which dose of unfractionated heparin is given to STEMI patients?

15. Which loading dose of acetylsalicylic acid is given to STEMI patients?

16. Which loading dose clopidogrel is given to STEMI patients?

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Kikkert, W.J., Piek, J.J., de Winter, R.J. et al. Guideline adherence for antithrombotic therapy in acute coronary syndrome: an overview in Dutch hospitals. NHJL 18, 291–300 (2010). https://doi.org/10.1007/BF03091779

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