Suboptimal Utilization of Secondary Drug Prevention in Acute Coronary Syndrome: Measurement Issues and Managed Care Opportunities

The management of patients with acute coronary syndrome (ACS), including unstable angina, non-ST segment elevation myocardial infarction (non-STEMI), and ST segment elevation myocardial infarction (STEMI), continues to be a challenge for the health care industry. Despite numerous health care advances, ACS remains a major source of both morbidity and mortality. In 2005, there were approximately 772,000 patients with ACS discharged from hospitals in the United States.1 Further, myocardial infarction (MI) was the primary cause of death for nearly 157,000 Americans in 2004 and a contributing cause of death for approximately 40,000 additional persons.1 In addition to primary prevention efforts, joint guidelines by the American College of Cardiology (ACC) and the American Heart Association (AHA) suggest secondary drug prevention measures to be used in patients with ACS.2,3 In conjunction with diet and lifestyle modifications, these guidelines suggest the use of statin, beta-blocker, and renin-angiotensin aldosterone system inhibitor drug therapies in ACS patients.2,3 Unfortunately, the benefits of these drug therapies can be realized only if they are routinely used in clinical practice. Adoption and maintenance of such therapies requires commitment by patients, providers, and the health care system. The article by Lee et al. in this issue of JMCP estimates compliance with ACC/AHA-recommended treatments, including statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARBs), following ACS hospitalizations.4 Lee et al. used pharmacy and medical insurance claims data for patients admitted to the hospital for ACS (from July 2003 through June 2004) and concluded that post-discharge secondary prevention was suboptimal, especially when evaluating the percentage of patients prescribed all 3 medication classes concomitantly.4 Further, the authors concluded that treatment rates varied by age (i.e., patients aged ≥ 80 years were less likely to receive any of the therapies), gender (i.e., women were less likely than men to receive statins), and specific diagnoses (i.e., patients with intermediate coronary syndrome were less likely than patients with MI to receive any of the study medications). As managed care pharmacists, providers, and administrators seek to improve the quality of care for their patient populations, these findings suggest that secondary drug therapy following a hospitalization for ACS is one potential area for improvement. Although largely descriptive, the study provides insight into the treatment patterns of a real-world population of persons with a recent coronary event, and the authors are to be commended for publishing these data. Despite the relevance and timeliness of these findings, it is important to highlight and discuss several important limitations of these analyses (measurement issues) that should be considered alongside the results of this study. In addition, Lee et al.’s work also serves as a springboard for a larger discussion of several prominent opportunities for managed care.