Improved adherence to guideline-recommended treatments in a specialist preventative pharmacology clinic compared to standard cardiology clinics after an acute coronary syndrome
Authors: Thomas M R , Desai N , Khan N , Hargreaves O , Khashaba A , Khattak S , George S , Dawson C , Townend J 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): West Midlands Academic Health Science Network.

Background
After an acute coronary syndrome (ACS), there is a persistent ~10% risk of recurrent ACS or death in the following year and a further ~10% risk between years 1-4. Several more recent guideline-recommended treatments that could reduce this risk (Knuuti et al 2019) and may be under-utilised. Some of these, such as long-term dual antithrombotic therapy, are recommended for patients with high cardiovascular risk. Others benefit patients with type 2 diabetes mellitus (SGLT2 inhibitors and GLP1 agonists), hypercholesterolaemia (ezetimibe and PCSK9 inhibitors) or heart failure (mineralocorticoid antagonists and sacubitril/valsartan in addition to ACE inhibitors and beta blockers).

Methods
We were recently awarded funding from the West Midlands Academic Health Science Network (UK) to introduce a new advanced secondary prevention clinic that focusses on more recent medications with recommendations from National Institute for Health and Care Excellence (NICE NG185 and relevant technology appraisals) and the ESC. In an audit we compared use of medications in the prevention clinic (n=57) with similar patients with prior ACS seen in standard cardiology clinics (n=109) between 2020-21 in our National Health Service (NHS) Trust (Fig 1.).

Results
Assessment of eligibility for medications was complex, but showed similar eligibility in prevention clinics and standard clinics. Patients were uniformly eligible for statins and ACE inhibitors, whereas NICE and ESC guidelines in some cases disagreed on eligibility of individual patients for dual antithrombotic therapy, beta blockers and ezetimibe.
Use of treatments with definitive guideline recommendations from both NICE and ESC was determined for each patient (Fig 1). There was significantly higher adherence to these definitive recommendations in prevention vs. standard clinics (Fig 1), including SGLT2 inhibitors/GLP1 agonists (17/18 [94%] vs. 5/29 [17%]; P&lt;0.001), PCSK9 inhibitors (3/3 [100%] vs. 0/6 [0%]; P=0.01), ezetimibe (23/25 [92%] vs. 11/48 [23%]; P&lt;0.001], long-term dual antithrombotic therapy (22/23 [96%] vs. 3/31 [10%]; P&lt;0.001]) and statins at a recommended dose (52/53 [98%] vs. 82/101 [81%]; P&lt;0.001. Peer consultation identified several barriers to use of medications: complexity of treatment algorithms (which often differ between guidelines); need for personalisation (the audit identified &gt;50 unique combinations of recommended treatments for individual patients); complex risk assessments; and time constraints in gathering data to assess eligibility the medications (often takes &gt;5 min), exacerbated by high patient volume.

Conclusions
Several guideline-recommended medications with established cardiovascular benefit were under-utilised in standard clinics after ACS. Specialist preventative cardiology clinics can optimise utilisation of these medications, which has the potential to reduce the risk of further major adverse cardiovascular events. Innovative solutions are needed to scale this further.