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Original research
Secondary prevention therapies in acute coronary syndrome and relation to outcomes: observational study
  1. Clara K Chow1,2,
  2. David Brieger3,
  3. Mark Ryan4,
  4. Nadarajah Kangaharan5,
  5. Karice K Hyun6,
  6. Tom Briffa2
  7. for the CONCORDANCE Investigators
    1. 1 Westmead Applied Research Centre, Faculty of Medicine & Health, University of Sydney, Sydney, New South Wales, Australia
    2. 2 The George Institue of Global Health, Perth, Western Australia, Australia
    3. 3 Concord Repatriation General Hospital & The University of Sydney, Sydney, New South Wales, Australia
    4. 4 Deparatment of Cardiology, Shoalhaven District Memorial Hospital, Nowra, New South Wales, Australia
    5. 5 Royal Darwin Hospital, Casuarina, Northern Territory, Australia
    6. 6 ANZAC Research Institute, Sydney Medical School, University of Sydney, Sydney, Australia
    1. Correspondence to Dr Clara K Chow, Department of Cardiology, Westmead Applied Research Centre and Faculty of Medicine & Health, Westmead Hospital, University of Sydney, Sydney, Australia; cchow{at}georgeinstitute.org.au; clara.chow{at}sydney.edu.au

    Abstract

    Objective To ascertain the use of secondary prevention medications and cardiac rehabilitation after an acute coronary syndrome (ACS) and the impact on 2-year outcomes.

    Methods CONCORDANCE (Cooperative National Registry of Acute Coronary care, Guideline Adherence and Clinical Events) is a prospective, observational registry of 41 Australian hospitals. A representative sample of 6859 patients with an ACS and 6 months’ follow-up on 31 May 2016 were included. The main outcome measure was use of ≥75% of indicated medications (≥4/5 (or ≥3/4 if contraindicated) of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker, beta-blocker, lipid-lowering therapy, aspirin and other antiplatelet). Major adverse cardiovascular events (MACE) included myocardial infarction, stroke or cardiovascular death.

    Results The mean age was 65±13 years, 29% were women, and the mean Global Registry of Acute Coronary Events (GRACE) score was 106±30. At discharge, 92% were on aspirin, 93% lipid-lowering therapy, 78% beta-blocker, 74% ACE/angiotensin receptor blocker and 73% a second antiplatelet; 89% were taking ≥75% of medications at discharge, 78% at 6 months and 66% at 2 years. At 6 months, 38% attended cardiac rehabilitation, 58% received dietary advice and 32% of smokers reported quitting. Among 1896 patients followed to 2 years, death/MACE was less frequent among patients on ≥75% vs <75% of medications (8.3% vs 13.9%; adjusted OR 0.75, 95 % CI 0.56 to 0.99), and was less frequent in patients who attended versus who did not attend cardiac rehabilitation (4.6% vs 13.4%; adjusted OR 0.44, 95% CI 0.31 to 0.62).

    Conclusions Use of secondary prevention therapies diminishes over time following an ACS. Patients receiving secondary prevention had decreased rates of death and MACE at 2 years.

    • cardiac risk factors and prevention
    • acute coronary syndrome
    • acute myocardial infarction
    • medication adherence

    This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0

    https://doi.org/10.1136/heartasia-2018-011122

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      Footnotes

      • Collaborators CONCORDANCE Registry: principal investigator and study coordinator: Associate Professor David Brieger and Kitty Xu (Concord Hospital). Investigators and study coordinators: New South Wales: Associate Professor Jens Kilian and Jo-dee Myers (Bankstown-Lidcombe Hospital); Dr Ray Parkin and Anne Morrison (Bathurst Base Hospital); Dr Rohan Rajaratnam and Erin Tattam (Campbelltown Hospital); Dr Jonathon Waites and Clara Baldo (Coffs Harbour Hospital); Dr Kanishka Kamaladasa and Maria Davies (Dubbo Base Hospital); Dr Nicholas Collins and Elizabeth Nyman (John Hunter Hospital); Dr Adam Blenkhorn and Janice Boys (Lismore Base Hospital); Associate Professor Craig Juergens and Elza Plotz (Liverpool Hospital); Associate Professor Drew Fitzpatrick and Lisa Barry (Nepean Hospital); Dr David Amos and Estelle Ryan (Orange Health Service); Dr Mark Adams and Danica Watson (Royal Prince Alfred); Dr Kevin Alford and Rhonda Turnbull (Port Macquarie); Dr Mark Ryan and Karley Robinson (Shoalhaven District Memorial Hospital); Dr James Weaver and Prakriti Shrestha (St George Hospital); Dr Clara Chow and Tracy Tsang (Westmead Hospital); Dr Pratap Chandra Shetty and Renee Stubbs (Wollongong Hospital). Australian Capital Territory: Dr Ahmad Farshid and Pearle Taverner (Canberra Hospital). Northern Territory: Dr Nadarajah Kangaharan and Wendy Corkill (Alice Springs Hospital); Dr Marcus Ilton and Krystal Matthews (Royal Darwin Hospital). Queensland: Dr Steve Coverdale and Colleen Johnston (Nambour General Hospital); Associate Professor Darren Walters and Kathryn Stibijl (Prince Charles Hospital); Dr Rohan Jayasinghe and Helen Gunter (Gold Coast University Hospital); Dr John Atherton and Leeanne Palethorpe (Royal Brisbane and Women’s Hospital); Dr Penelope Astridge and Tracey Dalamaras (Toowoomba Health Service); Dr Raibhan Yadav and Tony Farley (Townsville). South Australia: Professor Derek Chew and Fiona Wollaston (Flinders Medical Centre); Associate Professor Christopher Zeitz and Jane Rose (Lyell McEwin); Associate Professor Christopher Zeitz and Marilyn Black (Queen Elizabeth Hospital). Victoria: Dr Paul Antonis and Janise McEwan (Monash Heart); Dr James Shaw and Renee Vandernet (Alfred Health); Associate Professor Omar Farouque and Louise Brown (Austin Hospital); Dr Justin Mariani and Renee Herbstreit (Bairnsdale Regional); Associate Professor Gishel New and Louise Roberts (Box Hill Hospital); Associate Professor John Amerena and Karen Forgarty (Barwon-Geelong Hospital); Associate Professor Willian van Gaal and Mary Park (Northern Hospital); Associate Professor Andrew MacIsaac and Jenny Wilson (St Vincent’s). Western Australia: Associate Professor Jamie Rankin and Mary Vorster (The Royal Perth Hospital); Professor Joseph Hung and Louise Ferguson (Sir Charles Gairdner Hospital). Tasmania: Dr Phillip Roberts-Thomson and Teresa Grabek (Royal Hobart Hospital); Dr Bhuwan Singh and Monika a’Campo (Launceston General).

      • Contributors CKC and DB made substantial contributions to the conception or design of the work. CKC, MR, NK and DB made substantial contributions to the acquisition, analysis or interpretation of data for the work. CKC drafted the work. MR, NK, KKH, TB and DB revised the manuscript critically for important intellectual content. All authors gave final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

      • Funding The CONCORDANCE registry has been supported by grants from AstraZeneca, Sanofi-Aventis, Merck Sharp and Dohme/Schering Plough Joint Venture, Eli Lilly, Boehringer Ingelheim, the National Heart Foundation of Australia, and the National Health and Medical Research Council postgraduate scholarship funding programme. The funders had no role in the study design, data collection and analysis, decision to publish, or drafting of the manuscript. The researchers were independent from the funders. CK Chow is supported by National Health and Medical Research Council of Australia Career Development Fellowship (APP1105447) co-funded by the National Heart Foundation of Australia (100808).

      • Competing interests None declared.

      • Patient consent for publication Not required.

      • Ethics approval The study is performed according to Good Clinical Practice regulations, complies with local regulations and was approved by the research ethics committees at each participating site.

      • Provenance and peer review Not commissioned; externally peer reviewed.