PMC:6730630 / 2099-5928 JSONTXT

{"project":"2_test","denotations":[{"id":"31544164-26041770-15233842","span":{"begin":595,"end":596},"obj":"26041770"},{"id":"31544164-26041770-15233843","span":{"begin":686,"end":687},"obj":"26041770"},{"id":"31544164-24461715-15233844","span":{"begin":851,"end":852},"obj":"24461715"},{"id":"31544164-27206819-15233845","span":{"begin":1032,"end":1033},"obj":"27206819"},{"id":"31544164-27206819-15233846","span":{"begin":2620,"end":2621},"obj":"27206819"}],"text":"Problem\nNational Health Service (NHS) Greater Glasgow and Clyde is Scotland’s largest regional health authority, delivering primary, secondary and tertiary care to approximately 1.2 million residents. It encompasses seven local acute and ambulatory hospitals and six separate local council authorities. Three out of these six council authorities appear in the top 10 list of UK-wide authorities with the highest age-standardised death rates for cardiovascular disease (CVD), with Glasgow City having the highest overall rate with approximately 400 age-standardised deaths per 100 000 population.1 Scotland also has amongst the highest prevalence of coronary heart disease across the UK.1 Despite declining case fatality rates from myocardial infarction (MI) across the UK,2 3 patients have worse outcomes than those from comparable European countries.4\nThe optimisation of secondary prevention medication is crucial in improving outcomes for post-MI patients, especially in those with left ventricular systolic dysfunction (LVSD).5–7 ACE inhibitors (ACEI), or angiotensin II receptor blockers (ARB) if the patient is intolerant, and beta-blockers are first-line agents for such patients and should be prescribed in all patients unless contraindicated.7 These medications should be optimised early in the postdischarge phase, ideally utilising non-medical prescribers.7 8\nWithin NHS Greater Glasgow and Clyde, baseline acute MI care involved patients being initiated on ACEI (or ARB) and beta-blocker during their admission. These medications were then reviewed postdischarge by cardiac rehabilitation nurses and recommendations were made to general practitioners (GPs) about medication optimisation goals as part of a broader review. Cardiologist outpatient clinic follow-up typically took place 6–12 months postdischarge. Patients with post-MI LVSD without overt clinical heart failure (HF) were not routinely reviewed by HF nurses.\nAt cardiologist-led clinic follow-up visits, it was noted that many patients were not being prescribed evidence-based therapy at fully optimised doses. Therefore, a baseline audit of care data was conducted in two local hospitals to characterise care—Royal Alexandra Hospital and Vale of Leven. Data were collected through retrospective audit of the cardiac rehabilitation databases and electronic patient records for all consecutive patients with incident acute MI and moderate or severe LVSD on echocardiography over 12 months (1 September 2012–31 August 2013). The endpoints were: the percentage of patients treated with, mean percentage of European Society of Cardiology target dose5 achieved and percentage of patients on full target dose of ACEI/ARB and beta-blocker at the end of the formal cardiac rehabilitation programme. The target daily doses used were: ramipril 10 mg, enalapril 20 mg, lisinopril 20 mg, candesartan 32 mg, losartan 150 mg, valsartan 320 mg, bisoprolol 10 mg, carvedilol 50 mg and nebivolol 10 mg.\nFifty-seven patients with moderate or severe post-MI LVSD were identified. Baseline overall use of ACEI (or ARB) was 89% (n=51/57). The mean percentage of ACEI (or ARB) target dose was 44%, with 21% (n=12/57) of patients achieving the full target dose. Baseline use of beta-blocker was 82% (n=47/57). The mean percentage of beta-blocker target dose was 31%, with 7% (n=4/57) of patients achieving the full target dose.\nThe Specific Measurable Achievable Realistic Time-limited aim of our programme was to improve the use and target dosing of ACEI (or ARB) and beta-blocker in all patients with LVSD secondary to incident acute MI across a large regional health authority by the end of a patient’s cardiac rehabilitation programme, typically within 4 months of discharge from hospital, through pharmacist-led clinics and cardiology multidisciplinary team collaboration."}