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Year : 2009  |  Volume : 10  |  Issue : 1  |  Page : 6-10 Table of Contents     

The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race)


Date of Web Publication17-Jun-2010

Correspondence Address:
Mohammad Zubaid
Department of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait

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Source of Support: None, Conflict of Interest: None

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Backgrounds: The use of certain medications in acute myocardial infarction (AMI) is known to lower morbidity and mortality. We aimed to evaluate, through the use of performance measures, the implementation of specific guidelines-recommended pharmacotherapy in the management of AMI in patients living in the Arabian Peninsula.
Materials and Methods: The Gulf Registry of Acute Coronary Events (Gulf RACE) enrolled ACS patients from 6 countries in the Arabian Peninsula. We examined the use of 7 performance measures that relate to the management of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI).
Results: 5833 AMI patients were enrolled in Gulf RACE. In the first 24 hours of hospital arrival, 5713 (98%) patients were administered aspirin. The prescription rate at discharge was 5376 (97%) for aspirin, 4354 (78%) for beta-blockers, 5639 (84%) for statins and 3145 (57%) for clopidogrel. Left ventricular systolic function (LVSF) was evaluated in 3861 (66%) patients. Of those who had ejection fraction < 40% (921 patients), 725 (85%) received angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at discharge.
Conclusion: There was good adherence to guidelines-recommended medications in patients admitted to hospital with a diagnosis of AMI. The implementation of more performance measures need to be evaluated in order to assess the full picture of AMI management in this part of the world.

Keywords: myocardial infarction, gulf race, acute coronary syndrome

How to cite this article:
Al Shukry A, Rashed W, Zubaid M. The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race). Heart Views 2009;10:6-10

How to cite this URL:
Al Shukry A, Rashed W, Zubaid M. The use of evidence-based therapy in acute myocardial infarction patients admitted to hospital during the Gulf registry of acute coronary events (Gulf Race). Heart Views [serial online] 2009 [cited 2023 Mar 28];10:6-10. Available from: https://www.heartviews.org/text.asp?2009/10/1/6/63833

   Introduction Top

According to the World Health Organization (WHO), cardiovascular disease is estimated to become the leading cause of death in developing countries by 2010 [1] . Therefore, the incidence of acute myocardial infarction (AMI) in the Middle East is expected to rise. For those who survive an initial AMI, the risk of further cardiovascular problems, including recurrent myocardial infarction, sudden cardiac death, heart failure, and stroke is substantial [2],[3] . Studies have shown that advances in cardiovascular care over the past years have reduced mortality and morbidity associated with AMI [4] , however there still remains a gap between the care delivered and that which ought to be delivered to these patients [5],[6] . Guidelines for the management of different cardiovascular diseases, including AMI have been developed to bridge this gap [7],[8] . The American Heart Association (AHA) and the American College of Cardiology (ACC) have developed a list of specific performance measures that can be evaluated in the management of AMI [9] . The degree of implementation of these performance measures in any institution reflects the quality of care at that institution.

In this study, we evaluate specific aspects of the quality of care provided to AMI patients enrolled in the Gulf Registry of Acute Coronary Events (Gulf RACE), through the assessment of the implementation of some of the performance measures recommended by the AHA/ACC. The purpose of this effort is to allow practitioners and institutions in the Arabian Gulf to measure and assess the quality of their medical care and to enable visualization of specific areas requiring improvement.

   Methodology Top

Gulf RACE is a Gulf Heart Association (GHA) project. It was a 6-month prospective, observational study of consecutive ACS patients recruited from 64 hospitals in 6 Middle Eastern countries. The 6 participating countries were Bahrain, Kuwait, Qatar, Oman, United Arab Emirates (UAE) and Yemen. The study received ethical approval from the institutional ethical bodies in all participating countries. In Bahrain, Kuwait and Qatar, all hospitals nationwide that admit patients with ACS participated in the survey. In Oman, UAE and Yemen, most hospitals (covering at least 85% of the population) participated in the survey. Full details of the methods have been published previously [10] . Briefly, patients' data were collected using standardized case report form (CRF). These included patients' demographics, past medical history, provisional diagnosis on admission and discharge, clinical features at hospital presentation, ECG findings, laboratory investigations, early in-hospital medications (administered within 24 hours of admission), discharge medications, use of cardiac procedures and interventions, in-hospital outcomes and in-hospital mortality. The management of AMI patients in Gulf RACE was left to the discretion of the treating physician. Recruitment in the pilot phase started on May 8, 2006 for 30 days. Enrolment in the next phase of the registry started on January 29, 2007 and continued for 5 months. We report on patients with AMI recruited during the entire 6 months of the registry.

In this report, we evaluated the performance of the enrolling hospitals in relation to the use of seven specific evidence-based measures derived from the AHA and ACC performance measures for the management of STEMI and NSTEMI [9] . These performance measures were the following: use of aspirin within 24 hours of hospital arrival; evaluation of left ventricular systolic function (LVSF) during hospitalization or planning it after discharge; use of angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) in patients with left ventricular ejection fraction (LVEF) less than 40%; prescription of aspirin at hospital discharge; prescription of a beta-blocker at hospital discharge; prescription of a statin at hospital discharge; prescription of clopidogrel at hospital discharge.

Statistical Analysis

Baseline and clinical characteristics of patients were presented as frequencies and means. All data analyses were carried out using the Statistical Package for Social Sciences version 14 (SPSS Inc. USA).

   Results Top

Patient Characteristics

5833 patients with the final diagnosis of AMI were recruited in Gulf RACE. 3096 (53%) patients were diagnosed with ST-segment elevation myocardial infarction (STEMI), 106 (2%) patients were diagnosed with left bundle branch block myocardial infarction (LBBBMI) and 2631 (45%) were diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). The mean age in this cohort was 56.612.4 years. 4738 (81%) were males and 1095 (19%) were females [Table 1]. Risk factors for coronary artery disease were common among patients, with 2280 (39%) patients suffering from diabetes and 2437 (42%) were active smokers. The recruitment per country is shown in [Figure 1].

Evaluation of Performance Measures

Of 5833 patients admitted with AMI, aspirin was administered to 5713 (98%) patients within 24 hours of hospital arrival [Table 2]. At hospital discharge, 5376 (97%) patients were prescribed aspirin, 4354 (78%) patients were prescribed a beta-blocker, 4639 (48%) were prescribed a statin and 3145 (57%) of patients were prescribed clopidogrel. 3861 (66%) patients underwent evaluation of LVSF by either echocardiography or coronary angiography, of whom 921 had LVEF < 40%. Of the 921 patients with LVEF < 40%, 725 (85%) received ACEI/ARB at discharge.

   Discussion Top

This is the first report that examines the adherence of hospitals that participated in Gulf RACE to specific AHA/ACC performance measures9. This examination of local practice has enabled the formation of a plausible evaluation of the current quality of care provided to AMI patients in Gulf countries of the Middle East. Although guidelines provide recommendations for the use of different medications, they do not provide an estimate of the number of patients who, in the real world, would not be able to consume these medications. Therefore, in our evaluation of the implementation of these performance measures we compared our use of medications to established registries [11],[12] . A comparison between our performance and other registries is shown in [Table 3].

Guidelines strongly recommend the early administration of aspirin to patients hospitalized with AMI and the continued use of aspirin at discharge [13] . Ninety eight percent of our patients were administered aspirin within 24 hours of hospital arrival and 97% were prescribed it at hospital discharge. The long-term use of beta-blocker therapy for the secondary prevention of cardiovascular events after AMI is strongly recommended by guidelines [13] . In Gulf RACE, 78% of our AMI patients were prescribed beta-blocker therapy at hospital discharge. Another performance measure we looked at was the prescription of a statin to patients at hospital discharge. There is unequivocal evidence supporting the use of statin therapy in patients who have suffered AMI. In Gulf RACE, 84% of our AMI patients were prescribed a statin at hospital discharge. Data on the benefits of combined anti-platelet therapy with clopidogrel and aspirin for ACS patients has been consistently increasing over the years [9] , and its efficacy has been proven by several trials [12],[13],[14],[15],[16],[17] . In Gulf RACE, 57% of our medically-treated AMI patients were prescribed clopidogrel at hospital discharge. We found that the implementation of the above 5 mentioned performance measures was well comparable to other ACS registries, namely the Euro Heart Survey of Acute Coronary Syndromes II (EHS-ACS-II) and the National Registry of Myocardial Infarctions (NRMI-5).

LVSF is an important prognostic indicator for patients with AMI [9] . After a myocardial infarction, about 50% of patients develop asymptomatic left ventricular systolic dysfunction (LVSD) [14] . Due to the lack of signs and symptoms of heart failure, a false sense of well-being may be created, depriving patients of vital treatments. Therefore, assessment of LVSF is essential [14] . Sixty six percent of AMI patients in Gulf RACE underwent LVSF evaluation through either echocardiography or coronary angiography. According to the AHA/ACC performance measures, AMI patients with LVSD and without contraindications should be prescribed an ACEI or ARB at hospital discharge. LVSD is defined as chart documentation of LVEF less than 40% or a narrative description of LVSF consistent with moderate or severe systolic dysfunction [9] . Eighty five percent of our AMI patients whose LVEF was less than 40% were prescribed ACEI or ARB therapy at hospital discharge.

The conclusions drawn from this evaluation are reassuring. Medical practitioners in the Gulf have implemented the selected performance measures in an effective manner. The implementation of these specific performance measures in Gulf RACE was comparable to their implementation in well-known AMI registries. On this basis, medical institutions that provide care for AMI patients must maintain this quality of care by undergoing continuing audits and feed back to clinicians with regards to their adherence to the AHA/ACC performance measures. Additionally, clinicians who look after AMI patients must be encouraged to strictly adhere to these performance measures and to clearly document the rationale behind omitting or not adhering to certain measures. Collectively, these efforts will allow hospitals to maintain high standards in the management of AMI patients.

   Limitations Top

One of the major limitations was that patient details were documented in Gulf RACE in the form of CRFs which did not include the reasoning behind the omission of certain medications or investigations. Therefore, reasons why certain medications were not administered or prescribed to eligible patients were not explored. Another limitation was the lack of knowledge about the estimated number of patients who would not be able to consume the recommended medications. This has led to the comparison with western registries, which might have not been accurately representative of standards that one should expect to meet in local hospitals.

   Acknowledgements Top

We would like to thank sanofi aventis-Gulf and Qatar Telecommunications Company for their funding of the registry. Special thanks to Miss Rihab Moneer for her help in the preparation of this manuscript.[18]

   References Top

1.American Heart Association. Statistical Fact Sheet - Populations. International Cardiovascular Disease Statistics, 2004.   Back to cited text no. 1      
2.Rosamond W, Flegal K, Furie K, et al. Heart disease and stroke statistics-2008 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2008; 117: 25-146.   Back to cited text no. 2      
3.Al Nozha M, Gaafar K, Abdel Kader F et al. Gulf Heart Association. Gulf Heart Association Guidelines on Acute Coronary Syndromes in Patients Presenting without Persistent ST-segment Elevation. [www.gulfheart.org/pdf/1.pdf] Accessed March 18, 09.   Back to cited text no. 3      
4.Fox KA, Steg PG, Eagle KA, et al. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA. 2007; 297: 1892-900.   Back to cited text no. 4      
5.EUROASPIRE I and II group. Clinical reality of coronary prevention guidelines: a comparison of EUROASPIRE I and II in nine countries. Lancet. 2001; 357: 995-1001.   Back to cited text no. 5      
6.Simoons ML, de Boer MJ, Boersma E, et al. Continuously improving the practice of cardiology. Neth Heart J. 2004; 12: 110-6.   Back to cited text no. 6      
7.Antman E, Hand M, Armstrong P et al. 2007 Focused Update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction. Circulation. 2008; 117: 296-329.   Back to cited text no. 7      
8.Anderson J, Adams C, Antman E et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction. Circulation. 2007; 116: 148-304.   Back to cited text no. 8      
9.Krumholz H, Anderson J, Bachelder D et al. ACC/AHA 2008 Performance Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction. Circulation. 2008; 118: 2596-2648.   Back to cited text no. 9      
10.Zubaid M, Rashed W, Al-Khaja N et al. Clinical presentation and outcomes of acute coronary syndromes in the Gulf Registry of Acute Coronary Events (Gulf RACE). Saudi Med J. 2008: 29(2): 251-255.   Back to cited text no. 10      
11.Mandelzweig L, Battler A, Boyko V et al. The second Euro Heart Survey on acute coronary syndromes: characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. European Heart Journal. 2006; 27(19): 2285-2293.   Back to cited text no. 11      
12.Fonarow GC, French WJ, Frederick PD et al. Trends in the use of lipid-lowering medications at discharge in patients with acute myocardial infarction: 1998 to 2006. Am Heart J. 2009 Jan; 157(1): 185-194.e2   Back to cited text no. 12      
13.Antman EM, Anbe DT, Armstrong PW et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.   Back to cited text no. 13      
14.Albert NM, Lewis C. Recognizing and Managing Asymptomatic Left Ventricular Dysfunction: After Myocardial Infarction. Critical Care Nurse. 2008; 28: 20-37.   Back to cited text no. 14      
15.Sabatine MS, Cannon CP, Gibson CM et al, for the CLARITY-TIMI 28 investigators. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med. 2005; 352: 1179-1189.   Back to cited text no. 15      
16.COMMIT (ClOpidogrel and Metoprolol in Myocardial Infarction Trial) collaborative group. Addition of clopidogrel to aspirin in 45 852 patients with acute myocardial infarction: randomised placebo-controlled trial. Lancet. 2005; 366: 1607-21.   Back to cited text no. 16      
17.COMMIT/CCS-2-clopidogrel. ACC Current Journal Review. May 2005; 14(5): 10. DOI: 10.1016/j.accreview.2005.04.065. [http://www.journals.elsevierhealth.com/periodicals/acj/article/PIIS1062145805003557/fulltext]. 26/03/2009.   Back to cited text no. 17      
18.Jackson M, Fairman K, Curtiss F. Prior Authorization and Clopidogrel Use - The Truth Lies in the Details. Journal of Managed Care Pharmacy. 2009; 15(1): 71-77.  Back to cited text no. 18      


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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