University of Groningen
Medication use for acute coronary syndrome in Vietnam
Nguyen, Thang
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Chapter 2
Physicians’ adherence to acute coronary
syndrome prescribing guidelines
in Vietnamese hospital practice:
a cross‑sectional study
Thang Nguyen, Thao H Nguyen, Hoa TK Pham, Thu TA Nguyen,
Khoa M Huynh, Phuong TB Vo, Tam T Pham, Katja Taxis
Abstract
OBJECTIVES: To determine the extent of physician adherence to acute coronary syndrome (ACS) prescribing guidelines in Vietnamese hospital practice.
METHODS: A retrospective cross‑sectional study was performed collecting data from medical records of all patients with ACS admitted to two public hospitals in Ho Chi Minh city, Vietnam from January to December, 2013. Data were analyzed to determine the percentages of eligible patients receiving guideline‑recommended medications at hospital arrival and discharge and to identify factors associated with non‑adherence using multivariable logistic regression.
RESULTS: A total of 284 patients were included (mean age 64 years; 69.4% male). Of those patients eligible for treatment, aspirin was prescribed for 97.9% at arrival and 96.3% at discharge; dual antiplatelet therapy was prescribed for 92.3% at arrival and 91.7% at discharge; loading doses at arrival were prescribed for 79.5% (aspirin) and 55.8% (clopidogrel); beta blockers were prescribed for 58.7% at arrival and 76.7% at discharge; angiotensin converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) were prescribed for 89.1% at arrival and discharge; and statins were prescribed for 94.1% at arrival and 90.7% at discharge. Patients who underwent an invasive procedure were more likely to receive guideline‑ recommended medications at discharge: dual antiplatelet therapy (OR 3.77; 95% CI 1.23–11.52), beta blocker (OR 3.95; 95% CI 1.86–8.40), and ACEI/ ARB (OR 4.01; 95% CI 1.30–12.41).
CONCLUSIONS: In general, physicians closely adhered to ACS prescribing guidelines in Vietnamese hospital practice, but prescribing of beta blockers and clopidogrel loading doses was probably suboptimal.
Introduction
Ischemic heart disease (IHD) is among the leading causes of death worldwide. In 2008, 7.3 million people died due to IHD (12.7% of total global mortality).1 Low‑and‑middle
income countries accounted for more than 80% of those.1 IHD comprises a spectrum of
diseases of the heart including acute coronary syndrome (ACS) which is the main cause of IHD deaths.2 Patients with ACS suffer from myocardial ischemia. There are three types
of ACS: ST elevation (formerly Q‑wave) myocardial infarction (STEMI), non‑ST elevation (formerly non‑Q wave) myocardial infarction (NSTEMI), and unstable angina (UA).3
International guidelines recommend using a combination of two antiplatelet agents (aspirin plus clopidogrel), a beta blocker, an angiotensin converting enzyme inhibitor or an angiotensin II receptor blocker (ACEI/ARB) and an HMG coenzyme A reductase inhibitor (statin) to treat patients with ACS.3–7 This regimen has been shown to reduce in‑hospital
and postdischarge mortality rates in ACS patients.8,9 For example, an observational study of
almost 65,000 patients with NSTEMI showed that every 10 percent increase in adherence to prescribe guideline‑recommended treatment was associated with a 10 percent reduction in in‑hospital mortality (adjusted odds ratio 0.90, 95% CI 0.84–0.97). In‑hospital mortality was significantly lower in the hospitals with the highest compared to the lowest adherence quartile (4.2% versus 6.3%).9 Despite such evidence, adherence to guidelines remains subop‑
timal,10–15 in particular, in low‑ and middle‑income countries.16–18 Shimony et al. (2014)17
showed that patients from high‑income countries (Canada and United States) were more likely to receive guideline‑recommended medications at discharge (OR 2.32, 95% CI 1.19–4.52, a combination of aspirin, clopidogrel, and a statin) than those in low‑ and middle‑ income countries (India, Iran, Pakistan, and Tunisia).
In Vietnam, ischemic heart disease was one of the major leading causes of death across all ages in 2007.19 The Vietnam National Heart Association (VNHA) published the first
guidelines on management of ACS in 2006 with an update in 2008.20 VNHA guidelines are
in line with international guidelines in their recommendations of prescribing evidence‑based medications.3–7,20 However, in contrast to some other Asian countries, little is known about
the prescribing patterns for patients with ACS during hospitalization and after discharge in Vietnamese hospitals. Therefore, we determined the extent of physician adherence to acute coronary syndrome (ACS) prescribing guidelines in Vietnamese hospital practice.
26
Chapter 2
Methods
A retrospective cross‑sectional study was performed of all patients admitted with a diagnosis of ACS to the study hospitals between January and December 2013. The study was carried out in two public hospitals (provincial level), comprising 1200 beds (hospital A) and 700 beds (hospital B). Study wards were: Cardiology, Internal Medicine, Intensive Care Unit and Cardiac Intensive Care Unit. On the Cardiology wards, hospital A employed 26 physi‑ cians and had 52 beds; and hospital B employed 14 physicians and had 60 beds. Invasive procedures could be performed in both hospitals.
We included patients who survived during hospitalization with one of following discharge diagnoses according to coding of the International Classification of Diseases, 10th revision (ICD‑10): unstable angina (I20.0), acute myocardial infarction (I21), or subse‑ quent myocardial infarction (I22).21 For patients who were admitted several times during the study period, we only included the medical record of the first admission. We excluded patients (1) who had been admitted to another hospital initially and were transferred to the study site consequently; (2) who did not fully complete treatment therapy (i.e. patients who were transferred to another hospital for further treatment or patients who were discharged with or without permission of their physician when the therapy was incomplete); or (3) with missing data of arrival or discharge medications in their medical records.
All medical records of patients with a diagnosis of angina or ACS (I20, I21 and I22) were requested from the hospital record archives. Information from medical records was extracted by two researchers (KMH and PTBV) using a predefined data collection form. Data included: age, sex, health insurance, length of hospital stay, coronary artery disease risk factors, medical history of myocardial infarction, invasive procedures [including percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG)], comorbidities (peptic ulcer, asthma/COPD, renal failure, hepatic failure and heart failure), in‑hospital revascularization [invasive procedure (PCI or CABG) or non‑invasive procedure (with or without fibrinolysis)], Global Registry of Acute Coronary Events prediction score for all‑cause mortality in the first 6 months after discharge (GRACE score),22 and labora‑
tory examinations. Details of all medications prescribed within the first 24 hours after hospital admission and at hospital discharge were collected (brand and generic name of the medication, dose, dosage form, administration route, and frequency of administra‑ tion). Information on contraindications to antiplatelet therapy, beta blockers, ACEI/ARBs or statins was also recorded.
Data were analyzed (1) to determine the percentages of eligible patients who were prescribed guideline‑recommended medications during the first 24 hours of hospitaliza‑ tion and at hospital discharge and (2) to identify factors associated with non‑adherence to prescribing guideline‑recommended medications.
Physician adherence to prescribing ACS guidelines in Vietnam
Guidelines used in this study were the current version of the Vietnam National Heart Association (VNHA), the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA). All three guidelines recommend use of two antiplatelet agents (aspirin and clopidogrel), a beta blocker, an ACEI/ARB and a statin within the first 24 hours after hospital admission (hereafter called “at arrival”) and at hospital discharge. This is a class I recommendation, i.e., the treatment should be given because of its benefit, usefulness or efficacy and supported by a high level of evidence (level A, data derived from multiple randomized clinical trials or meta‑analysis; or level B, data derived from a single randomized or large non‑randomized studies); with the exception of prescribing ACEI/ARB at arrival (not recommended in the ESC guidelines) or statin at arrival (not recommended in ACC/AHA guidelines and VNHA guideline for STEMI) (Appendix 1).3–7,20
The percentage of eligible patients receiving a guideline‑recommended medication was calculated by dividing the number of eligible patients who were prescribed the medica‑ tion by the total number of eligible patients who should be prescribed the medication, multiplied by 100. Eligible patients for being prescribed aspirin, a loading dose of aspirin, dual antiplatelet therapy, a beta blocker or a statin were patients without contraindications to the medications. Eligible patients for being prescribed a loading dose of clopidogrel were patients younger than 75 years of age without contraindications to clopidogrel. Eligible patients for being prescribed an ACEI/ARB were patients with heart failure, a left ventricular ejection fraction (LVEF) < 40%, diabetes mellitus, or hypertension and without contraindi‑ cations to ACEI/ARBs. Contraindications were based on the current guidelines,4–7,20 AHFS
Drug Information (2012),23 Facts and Comparisons (2013)24 and the Vietnamese National
Formulary (2012)25 (Appendix 2). A patient with ACS and no relevant contraindications
was likely to be prescribed the following six discharge medications: two antiplatelet agents (aspirin and clopidogrel), a beta blocker, an ACEI/ARB, a statin and a proton pump inhibitor (protection against gastrointestinal side effects of antiplatelet therapy).
Data were analyzed using the Statistical Package for the Social Sciences, version 20th (SPSS 20). Multivariable logistic regression with forward stepwise method was performed to identify potential factors associated with guideline non‑adherence at arrival or discharge. The following variables were included in the multivariable model: age group (age ≥ 65 versus < 65 years); sex (male vs. female); diagnosis (NSTEMI vs. UA and STEMI vs. UA), health insurance; previously diagnosed diabetes mellitus, hypertension, dyslipidemia, myocardial infarction, heart failure; in‑hospital revascularization (invasive vs. non‑invasive procedure) (only for discharge recommendations); GRACE score (moderate vs. low risk and high vs. low risk) (only for discharge recommendations); number of discharge medications ( > 6 vs. ≤6 medications) (only for discharge recommendations). Patients with documented contraindications to the studied agents were excluded from this analysis.
28
Chapter 2
Results
A total of 711 medical records of patients with a diagnosis of angina or ACS were identified and 284 patients were included in the study (Figure 1). The following medical records were excluded: 270 records of patients with a discharge diagnosis of unspecified angina or stable angina, and 7 records of second admissions; and 150 records because of exclusion criteria: 60 patients who had been admitted to another hospital initially and were transferred to the study site consequently, 90 patients who did not fully complete treatment therapy: 13 were transferred to another hospital for further treatment, 61 were discharged with permission of their physician when the therapy was incomplete, and 16 without physician permission.
The patients had a mean age of 64 years (range 30 to 105 years); 47% of the patients were over 65 years old (Table 1). The majority of patients were male (69.4%) and had hypertension (67%). Fifty five (18.7%) reported prior MI and 22 (7.7%) had prior PCI; 128 (45.1%) patients underwent PCI, 4 (1.4%) underwent CABG, and 152 (53.5%) had no invasive procedure and received pharmacological treatment with fibrinolysis (3 patients) or without fibrinolysis (149 patients); 191 (67.3%) patients had a moderate or high risk and 85 (29.9%) had a low risk of death within 6 months after hospital discharge. The risk of the remaining patients remained unknown because of missing data.
Aspirin was prescribed for 97.9% of eligible patients at arrival and 96.3% at discharge (Table 2). Fewer patients received an aspirin loading dose (79.5%) and a clopidogrel loading dose (55.8%). Documented contraindications for antiplatelet agents were intracranial hemorrhage, gastrointestinal (GI) bleeding, bleeding disorders, active GI ulcer, or asthma/ chronic obstructive pulmonary disease (COPD). Multivariable analysis showed that dual antiplatelet therapy at discharge was more frequently given to patients who underwent an invasive procedure during hospitalization or who received more than six discharge medications. STEMI patients were more likely than UA to receive an aspirin loading dose (Table 3). No factor was significantly associated with non‑adherence to prescribing a loading dose of clopidogrel.
Beta blockers were prescribed for 58.7% of eligible patients at arrival and 76.7% at discharge (Table 2). Documented contraindications to beta blockers were signs of heart failure, evidence of low output state, cardiogenic shock, second‑ or third‑degree heart block, or asthma. Patients with heart failure, STEMI (compared to UA), or female patients were less likely to receive a beta blocker at arrival. Patients were less frequently prescribed a beta blocker at discharge when they had no invasive procedure or when they had an NSTEMI (compared to UA) (Table 3).
Physician adherence to prescribing ACS guidelines in Vietnam
- Unspecified angina or stable angina (n= 270) - Second admission
cases (n=7)
Medical records of ACS or angina patients of hospital A
in 2013 (N = 417)
Medical records of ACS or angina patients of hospital B
in 2013 (N = 294)
Number of patients reviewed N = 434
Number of patients included N = 284
Excluded (n=150)
- Transferred from the other hospitals (n=60) - Incomplete therapies (n= 90) - Missing data (n=0) NSTEMI N = 113 (39.8%) Unstable angina N = 55 (19.4%) N = 116 (40.8%) STEMI Figure 1 Flowchart of the study population
Abbreviations: ACS, acute coronary syndrome; NSTEMI, non‑ST elevation myocardial infarction; STEMI, ST elevation myocardial
infarction; UA, unstable angina.
ACEI/ARBs were prescribed for 89.1% of eligible patients at arrival and at discharge (Table 2). Documented contraindications in patients not receiving ACEI/ARB were systolic blood pressure less than 100 mmHg, aortic valve stenosis, or glomerular filtration rate (GFR) less than 30 mL/min. Patients were less likely to receive an ACEI/ARB at hospital discharge when they had no invasive procedure (Table 3).
Statins were prescribed for 94.1% of eligible patients at arrival and 90.7% at discharge (Table 2). Documented contraindications to statins were elevations of hepatic transami‑ nases (3 times higher than the upper normal limits). No factor was significantly associated with non‑adherence to prescribing statins.
30
Chapter 2
Table 1 Patient characteristics Patient
characteristic (n = 284)Overall
Type of ACS UA
(n = 55) NSTEMI(n = 113) (n = 116)STEMI
Demographics and general characteristics
Mean age (±SD) 64.2 (±14.1) 63.6 (±11.5) 67.7 (±14.9) 61.0 (±13.6)
Age range 30–105 39–88 30–105 33–97
Male 197 (69.4) 37 (67.3) 64 (57.1) 94 (81.7) Insurance 176 (62) 46 (83.6) 71 (63.4) 58 (50.4) Length of hospital stay (days) 8 (1–41) 7 (2–38) 10 (1–41) 7 (2–40) Number of medications at discharge 6.9 (±1.5) 6.7 (±1.4) 7.4 (±1.6) 6.6 (±1.4) Number of discharge medications > 6 158 (55.6) 29 (52.7) 75 (66.4) 54 (46.6)
CAD risk factors
CAD family history 12 (4.2) 3 (5.5) 6 (5.3) 3 (2.6) Hypertension 193 (68) 42 (76.4) 84 (74.3) 67 (57.8) Diabetes 71 (25) 15 (27.3) 37 (32.7) 19 (16.4) Dyslipidemia 47 (16.5) 9 (16.4) 27 (23.9) 11 (9.5) Smoking 99 (34.9) 12 (21.8) 34 (30.1) 53 (45.7) CRP/fibrinogen increase 119 (41.9) 9 (16.4) 56 (49.6) 54 (46.6) Age ≥ 65 136 (47.9) 23 (41.8) 66 (58.4) 47 (40.5) Menopause 85 (29.9) 17 (30.9) 48 (42.5) 20 (17.2)
Medical history and comorbidities
Prior MI 55 (18.7) 20 (36.4) 28 (24.8) 5 (4.3) Prior undergone invasive procedure 24 (8.5) 7 (12.7) 9 (8) 9 (6.9) Peptic ulcer 28 (9.9) 3 (5.5) 10 (8.8) 15 (12.9) Asthma/COPD 20 (7) 4 (7.3) 12 (10.6) 4 (3.4) Renal failure 33 (11.6) 7 (12.7) 21 (18.6) 5 (4.3) Hepatic failure 5 (1.8) 0 2 (1.8) 3 (2.6) Heart failure 69 (24.3) 7 (12.7) 45 (39.8) 17 (14.7) In-hospital revascularization Invasive 1. (46.5) 14 (25.5) 37 (32.7) 81 (69.8) PCI 128 (45.1) 14 (25.5) 33 (29.2) 81 (69.8) CABG 4 (1.4) 0 4 (3.5) 0 Non‑invasive 152 (53.5) 41 (74.5) 76 (67.3) 35 (30.2) With fibrinolysis 3 (1.1) 0 0 3 (2.6) Without fibrinolysis 149 (52.5) 41 (74.5) 76 (67.3) 32 (27.6) GRACE score Low risk 85 (29.9) 17 (30.9) 21 (18.6) 47 (40.5) Moderate risk 74 (26.1) 21 (38.2) 22 (19.5) 31 (26.7) High risk 117 (41.2) 15 (27.3) 66 (58.4) 36 (31.0) Missing data 8 (2.8) 2 (3.6) 4 (3.5) 2 (1.7) Abbreviations: ACS, acute coronary syndrome; CABG, coronary artery bypass grafting; CAD, coronary artery disease; COPD,
chronic obstructive pulmonary disease; CRP, C‑reactive protein; GRACE, global registry of acute coronary events; MI, myocardial infarction; NSTEMI, non‑ST elevation myocardial infarction; PCI, percutaneous coronary intervention; SD, standard deviation; STEMI, ST elevation myocardial infarction; UA, unstable angina.
Physician adherence to prescribing ACS guidelines in Vietnam
Table 2 Utilization of guideline‑recommended medications Guideline
recommendation
Number of eligible patients receiving guideline-recommended
medication Number of eligible patients
Percentage of eligible patients receiving guideline-recommended medication At arrival Aspirin 191 195 97.9
Dual antiplatelet therapy 179 194 92.3
Aspirin loading dose 155 195 79.5
Clopidogrel loading dose 82 147 55.8
Beta blocker 84 143 58.7
ACEI/ARB 164 184 89.1
Statin 241 256 94.1
At discharge
Aspirin 208 216 96.3
Dual antiplatelet therapy 198 216 91.7
Beta blocker 168 219 76.7
ACEI/ARB 171 192 89.1
Statin 253 279 90.7
Abbreviations: ACEI/ARB, angiotensin converting enzyme inhibitor or angiotensin receptor blocker.
Table 3 Factors associated with guideline non‑adherence*
Guideline recommendation Factor Number of patients receiving guideline-recommended medication (%) Number of patients NOT receiving guideline-recommended medication (%) OR 95% CI p-value
Aspirin loading dose
at arrival ‑ STEMI** 76 (49.0) 7 (17.5) 6.1 2.2–17.0 0.001 Beta blocker at arrival ‑ Male 70 (83.3) 36 (61.0) 3.6 1.5–8.7 0.004 ‑ STEMI** 17 (28.8) 31 (52.5) 0.3 0.1–0.9 0.022 ‑ Heart failure 3 (3.6) 11 (18.6) 0.2 0.1–0.8 0.026 Dual antiplatelet at
discharge ‑ Invasive procedure 97 (49.0) 5 (27.8) 3.8 1.2–11.5 0.020 ‑ Discharge
medications >
6 110 (55.6) 5 (27.8) 4.6 1.5–14.0 0.007 Beta blocker at discharge ‑ NSTEMI** 54 (32.1) 28 (54.9) 0.3 0.1–0.7 0.007
‑ Invasive
procedure 96 (57.1) 14 (27.5) 4.0 1.9–8.4 < 0.001 ACEI/ARB at discharge ‑ Invasive
procedure 83 (48.5) 4 (19.0) 4.0 1.3–12.4 < 0.001 Abbreviations: ACEI/ARB, angiotensin converting enzyme inhibitor or angiotensin receptor blocker; CI, confidence interval;
NSTEMI, non‑ST elevation myocardial infarction; OR, odds ratio; STEMI, ST elevation myocardial infarction. (*) Using Multivariable Logistic Regression with Forward Stepwise Method
32
Chapter 2
Discussion
Our study provides insight into pharmacological management of ACS at arrival and discharge from two Vietnamese hospitals. In line with previous studies, ACS patients in our study had a mean age above 60 years, were predominantly male and frequently had chronic comorbidities (hypertension, dyslipidemia, and diabetes mellitus).16,26–28 In general,
physicians prescribed guideline‑recommended medications. Patients who underwent an invasive procedure were more likely to receive evidence‑based medications (aspirin plus clopidogrel, beta blocker, ACEI/ARB) at discharge. This was encouraging, but more eligible patients with ACS not undergoing an invasive procedure should receive the combination treatment.3–7,20 When our results were compared to the figures of other low‑ and middle‑
income countries in several previous studies,16,17 adherence to guidelines seemed relatively
higher for antiplatelet therapy, ACEI/ARBs and statins, but lower for beta blockers.
Almost all eligible patients were prescribed aspirin at arrival and discharge and most patients received dual antiplatelet therapy. These findings are similar to many other studies from around the world.27–31 Aspirin plays an essential role in ACS treatment.32,33 There is also
a lot of evidence to give a P2Y12 receptor blocker (e.g. clopidogrel) in addition to aspirin for up to 1 year following an ACS,34–36 but physicians may have concerns about the benefit‑risk
ratio and extra cost of the second antiplatelet agent clopidogrel. We observed a considerable lower rate of prescribing aspirin and clopidogrel loading doses, especially in UA patients. Guidelines recommend to give a loading dose of aspirin as soon as possible to any patient thought to have an ACS (UA, NSTEMI or STEMI) and add a clopidogrel loading dose in patients younger than 75 years of age.3–7,20,37–39 Further work needs to investigate reasons
for not following this advice.
The percentage of patients prescribed beta blockers at arrival was suboptimal and lower than observed in some other studies (from 65 to 83%).40–42 Multivariable analysis showed
that patients with STEMI (compared to UA), heart failure, or female patients were less likely to receive beta blockers at arrival. Underutilization of beta blockers, especially at arrival, may be because of physicians’ concerns about adverse reactions of beta blockers in patients with comorbidities such as diabetes mellitus or heart failure. The initiation of oral beta blockers at arrival is recommended for all ACS patients without contraindications. Patients with contra‑ indications should be reevaluated during hospital stay for beta blocker candidacy because of well‑established benefits of beta blockers for secondary prevention.4–7,20,43,44 Prescribing
beta blockers should be, therefore, improved focusing on female patients, and patients with heart failure or STEMI. Finally, we observed higher rates of using ACEI/ARBs and statins than previous studies.28–31 This is encouraging as recommendations in guidelines are based
on several trials supporting the role of ACEI/ARBs (ISIS‑4, GISSI‑3 trial etc.) and statins (PROVE‑IT TMI 22, MIRACL, A to Z trial etc.) in the management of ACS patients.45–49
Our study has several limitations that merit consideration. First, failure to adequately document clinical information in medical records may influence our results.
Physician adherence to prescribing ACS guidelines in Vietnam
Especially failure to document contraindications may have led to misclassify some patients as being eligible for a certain treatment. Second, due to administrative reasons we had to exclude cases of patients who died during hospitalization so our results are not generaliz‑ able to this patient group. Third, we also had to exclude a large number of patients who were discharged home although their therapy was incomplete. We believe that patients with incomplete therapy were either of advanced age and/or severely ill, so physicians considered that treatment was no longer beneficial; or could not pay for further hospital treatment probably because of not being insured. There was insufficient information in the medical notes to identify reasons for incomplete therapy and because of the retrospective nature of our study we could not collect additional information about this. Furthermore, we excluded a group of patients whose discharge diagnosis was unspecified angina. A proportion of those patients may have had unstable angina. We excluded these patient groups because of predefined exclusion criteria. Further work is needed to investigate the quality of diagnosis and treatment in these patient groups, especially lack of access to treatment.
Are our results generalizable to other hospitals in Vietnam? To discuss this we need to explain some details of the Vietnamese healthcare system. Currently, the healthcare system in Vietnam consists of a public‑private mix. The public sector plays a leading role in providing inpatient health services, accounting for 93.9% of total inpatient admissions in 2010.50 Care is provided at the following four levels in the public sector: community,
district, provincial and national level. About 50.8 million people were covered by social health insurance in 2010, accounting for 60% of the population.50,51 People without insurance have
to cover cost of all treatment themselves. Insured patients receive treatment at their primary health facility which is specified by their insurance, e.g. a provincial hospital in the neigh‑ bourhood, but could be referred to higher level treatment if medically necessary. If patients bypass their primary facility without a referral letter, they will have higher co‑payments.50
In Vietnam, life preserving treatment in the acute phase of an ACS can only be provided in hospitals at provincial and national level and in some private hospitals. It is not known which percentage of ACS patients are referred to this level of hospital treatment. Furthermore, there are differences between provincial hospitals; for example, not all hospitals at this level are equipped to undertake PCI procedures. Both study sites were provincial level hospitals. Therefore, our findings should be representative for ACS patients treated at provincial level hospitals with similar structure in Vietnam.
Conclusions
In general, physicians closely adhered to ACS prescribing guidelines in Vietnamese hospital practice, but prescribing of beta blockers and clopidogrel loading doses was probably
34
Chapter 2
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Physician adherence to prescribing ACS guidelines in Vietnam
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Appendix 1 Guideline recommendations for acute
coronary syndrome treatment*
Guideline
recommendation Description
Class and level of guideline recommendations VNHA ACC/AHA ESC
NS TEA CS STEA CS NS TEA CS STEA CS NS TEA CS STEA CS At arrival Aspirin
at arrival ACS patients without aspirin contraindications who received aspirin within the first 24 hours after hospital
admission. I I I‑A I‑A I‑A I‑A
Dual antiplatelet
therapy at arrival ACS patients without contraindications of aspirin and clopidogrel who received a combination of aspirin and clopidogrel within the first 24 hours after hospital admission.
I I I‑B I‑B I‑A I‑A Aspirin loading
dose at arrival ACS patients without aspirin contraindications who received an aspirin loading dose of 150–325 mg within
the first 24 hours after hospital admission. I I I‑B I‑B I‑A I‑A Clopidogrel
loading dose ACS patients younger than 75 years of age without clopidogrel contraindications who received a clopidogrel loading dose of 300–600 mg within the first 24 hours after hospital admission.
I I I‑B I‑B I‑A I‑A Beta blocker
at arrival ACS patients without beta blocker contraindications who received a beta blocker within the first 24 hours after
hospital admission. I I I‑B I‑B I‑A I‑A ACEI/ARB
at arrival ACS patients with evidence of heart failure, LVSD, diabetes or hypertension; and without ACEI/ARB contraindications who received an ACEI/ARB within the first 24 hours after hospital admission.
I I I‑A I‑A NA NA Statin
at arrival ACS without statin contraindications who received a statin within the first 24 hours after hospital admission. I NA NA NA I‑B I‑A
At discharge
Aspirin at
discharge ACS patients without aspirin contraindications who were prescribed aspirin at hospital discharge. I I I‑A I‑A I‑A I‑A Dual antiplatelet
therapy at discharge
ACS patients without contraindications of aspirin and clopidogrel who were prescribed a combination of aspirin
and clopidogrel at hospital discharge. I I I‑B I‑B I‑A I‑A Beta blocker
at discharge ACS patients without beta blocker contraindications who were prescribed a beta blocker at hospital discharge. I I I‑B I‑B I‑A I‑A ACEI/ARB
at discharge ACS patients with evidence of heart failure, LVSD, diabetes or hypertension; and without ACEI/ARB contraindications who were prescribed an ACEI/ARB at hospital discharge.
I I I‑A IIa‑A I‑A IIa‑A Statin
at discharge ACS patients without statin contraindications who were prescribed a statin at hospital discharge I I I‑A I‑B I‑B I‑A
* References 3–7,20
Abbreviations: I, class I of recommendation; I‑A, class I of recommendation and level A of evidence; I‑B, class I of recommendation
and level B of evidence; IIa‑A, class IIa of recommendation and level A of evidence; NA, Not Available.
ACC/AHA, American College of Cardiology Foundation/American Heart Association; ACEI/ARB, angiotensin converting enzyme inhibitor or angiotensin receptor blocker; ACS, acute coronary syndrome; ECS, European Society of Cardiology; LVSD, left ventric‑ ular systolic dysfunction; NSTEACS, non‑ST elevation acute coronary syndrome; STEMI, ST elevation acute coronary syndrome; VNHA, Vietnam National Heart Association.
Physician adherence to prescribing ACS guidelines in Vietnam
Appendix 2 Contraindications of
guideline-recommended medications*
Medication Contraindication
Aspirin Patients with (1) active bleeding (such as intracranial hemorrhage or GI bleeding); (2) bleeding disorders; (3) active GI ulcer; (4) aspirin allergy; or (5) asthma; (6) third trimester pregnancy. Clopidogrel Patients with (1) active bleeding; (2) clopidogrel allergy; or (3) planning to have a CABG within
5 days.
Beta blocker Patients with (1) signs of heart failure; (2) evidence of a low output state;
(3) increased risk for cardiogenic shock; (4) second‑ or third‑degree heart block; (5) asthma/ COPD; or (6) beta blocker allergy.
ACEI/ARB Patients with (1) history of angioedema due to ACEI/ARB, heredity or idiopathy; (2) SBP < 100mmHg; (3) bilateral renal artery stenosis; (4) aortic valve stenosis; (6) pregnancy; (7) GFR < 30 mL/min; or (8) ACEI/ARB allergy.
Statin Patients with (1) active liver disease or unexplained persistent elevations of hepatic transaminases (at least 3 times higher than UNL); (2) statin allergy; (3) pregnancy; (4) lactation.
* References 3–7,20,23–25
Abbreviations: ACEI/ARB, angiotensin converting enzyme inhibitor or angiotensin receptor blocker; GI, gastrointestinal; CABG,
