The need for pharmaceutical care in the prevention of coronary heart disease: an exploratory study in acute myocardial infarction patients
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Aim: To determine guideline-related pharmaceutical care issues for the prevention of coronary heart disease in hospitalised patients admitted for myocardial infarction (MI).
Methods: Consecutive patients admitted with a diagnosis of Q-wave MI to two large teaching hospitals were studied. Relevant patient medical and drug histories, co-morbidities and total cholesterol concentrations were recorded. Primary or secondary prevention treatment prior to admission was assessed using a data collection tool of 16 criteria developed from the Scottish Intercollegiate Guidelines Network (SIGN) guidelines.
Main outcome measures: Frequency of adherence to defined clinical guideline criteria.
Results: There were 167 patients reviewed (mean age 65 years, 111 males), representing possible candidates for primary prevention (n=98) or secondary prevention (n=69) based on absence or presence of past history of coronary heart disease (CHD), respectively. Possible primary prevention candidates: eight guideline-based criteria were developed from the SIGN guideline. There were 85 (87%) patients with a total cholesterol concentration available on admission of whom 56 (66%) had a predicted CHD risk ≥ 15% and 10 (12%) had CHD risk ≥ 30%. Of those with CHD risk ≥ 15% 6 (11%) had been receiving an anti-platelet agent and of those with CHD risk ≥ 30% only 1 (10%) was recorded as taking a statin. Of known hypertensives with CHD risk ≥ 15%, 21% (5/24) were not recorded as having received treatment. Secondary prevention candidates: a further eight guideline-based criteria were developed from the SIGN guidelines. There were 42/65 (65%) candidates for aspirin documented as receiving it. There were 22/47 (47%) of those who had a total cholesterol ≥ 5mmol/l and/or known history of hypercholesterolaemia receiving a statin (representing 76% of the known hypercholesterolaemic patients identified in the community). Of statin-treated patients with a cholesterol measured on admission, 44% (7/16) had cholesterol remaining ≥ 5mmol/l. β-blocker use was 27/62 (44%) and ACE inhibitors use was 11/31 (36%) of those eligible. Sublingual GTN was recorded in 36/69 (52%).
Conclusion: The study has identified opportunities for improved pharmaceutical care in primary and secondary CHD prevention among those destined to suffer an MI. Candidates for secondary prevention are potentially identifiable from community pharmacy patient medication records from which the contribution of pharmacists in primary care might be targeted. The findings were obtained during a period of evolution of the evidence-base and so they establish a baseline for future work.
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