Acute Coronary Syndrome: How to Empower Patients

Patients with a new diagnosis of acute coronary syndrome (ACS) often do not know a great deal about their disease, its treatment, or the lifestyle changes needed to prevent recurrence.¹ Restenosis is common (39% of patients) after percutaneous coronary intervention.² In addition, ACS recurrence lowers quality of life and is expensive.²

Pharmacists have the ability to improve outcomes and increase the quality of life of their patients. Early, individualized education leads to better self-care and greater satisfaction with that care.¹ Also, family and health care social support increases the perceived benefit,² which improves adherence with self-care and thereby improves outcomes.²

Self-Care

Self-care (eg, smoking cessation, regular health checks, medication adherence, diet, exercise) can prevent recurrence of ACS, but long-term adherence to self-care is key. Adherence to self-care depends on a patient’s beliefs, disease knowledge, overall ability to function, emotions (eg, anxiety, depression), and outside influences (eg, social and health care networks). Disease knowledge includes knowing about ACS characteristics, risk factors, medications, and dietary and exercise needs. Knowing more does not affect a patient’s anxiety, depression, or valuation of the benefits of self-care.²

Self-efficacy, which includes the ability to manage one’s own medications, smoking, diet, and exercise, notably influences self-care. Encourage your patients to see past the likely occurrence of reduced body function. Help them understand there will be setbacks that increase the perception of barriers, which can be overcome with a positive attitude.²

Patients may not like hearing it, but improvements in diet, as well as exercise and smoking cessation, can help.

Most individuals will adhere to self-care for a month after they are given an ACS diagnosis, but adherence drops at about 6 months after discharge from the hospital.² Smoking, combined with a lack of exercise or dietary restraint, for even 6 months after an ACS incident, increases nearly 4-fold the incidence of acute myocardial infarction, stroke, and death.² Regular monitoring and education on the benefits of diet and exercise, can improve patient adherence to healthy behaviors.²

Lack of exercise, including excessive sitting, increases cardiac morbidity and mortality.3 At least a half hour of moderate exercise 5 times per week is recommended for patients who have been cleared for exercise by their doctor.³ Even moving, rather than sitting for extended periods, has health benefits for everyone.³ Having a workout program increases the likelihood of continuing to exercise.²

It has repeatedly been shown that heart health can be improved and heart attacks prevented by having a healthy diet; engaging in physical activity; maintaining a healthy body weight, blood pressure and cholesterol levels; and reducing or eliminating alcohol and smoking. Healthy diets known to help patients with ACS, include the Mediterranean diet and a diet high in fruits, vegetables, whole grains, and seafood, with limited salt and sugar. Simply having a healthy diet and limiting alcohol reduces heart attack risk by onethird. The combination of a healthy diet, moderate alcohol use, moderate exercise (4-5 hours a week), smoking cessation, normal blood pressure and cholesterol levels, and a healthy body mass index decreases a woman’s chance of a first heart attack by 92%.⁴

Medication Adherence

ACS management has improved with the use of interventional treatment strategies, antiplatelet drugs, and riskmodifying drugs.⁵ Outcomes after ACS are optimized by revascularization and aggressive medication therapy, including the use of anticoagulants and lipidlowering medications.⁶

Once blood vessels are damaged, arterial plaque is more prone to forming.⁶ The risk of recurrence is high soon after the incident (within 1 month) and for the long term.⁵ A high cholesterol level, high blood pressure, diabetes, and smoking encourage clot formation.⁶ Statins are typically started, even if the cholesterol level is not particularly high, with a low-density lipoprotein goal of 100 mg/dL or lower.⁶ For patients with unstable angina, pravastatin can reduce the death rate by one-fourth, as well as reduce the risk of subsequent myocardial infarctions, coronary revascularization, and stroke.⁶

After an ACS episode, use of nonsteroidal anti-inflammatory drugs, other than aspirin, should be stopped, as they increase cardiovascular risks and increase the bleeding risk associated with many anticoagulants. Anticoagulants, however, are often prescribed after an ACS episode.⁶

Anticoagulants are used as secondary prevention after a diagnosis of ACS. Dabigatran, apixaban, rivaroxaban, edoxaban, and warfarin all reduce the risk for stroke, intracranial hemorrhage, and systemic embolism. Because warfarin requires regular monitoring, it is being used less often for treating ACS. The newer oral agents may be preferred to warfarin because they are easier to take, regular monitoring is not required, and they do not have dietary interactions. Bleeding is always a risk with the use of any anticoagulant. Dual antiplatelet treatments (eg, aspirin and clopidogrel) are commonly used, but increase the risk for major bleeding. The efficacy of ticagrelor and prasugrel compares favorably to clopidogrel for reducing ischemic events in patients with ACS. Pharmacists should help patients understand that anticoagulants are often lifelong treatments.⁵

Your Input Matters

Support from family and health care providers can promote self-efficacy.² If you notice patients not refilling their prescriptions, you have the opportunity to point out the benefits of taking their medications regularly.⁷ If you detect frequent divergence from prescribed medication, it may warrant notification of the patient’s primary physician. Statins significantly reduce morbidity and mortality in coronary artery disease, but only if they are taken regularly.⁷ Benefits of statins are only seen after 1 to 2 years of continuous use.⁷

Lifestyle modifications (primarily diet and exercise) are effective for reducing coronary heart disease, but are rarely adhered to despite being, safe, inexpensive, and helpful (Table⁴).⁴ Social support can decrease anxiety and promote the benefits of self-care.² Pharmacists can also provide support by encouraging patients to care for themselves, promoting the benefits of self-care, and reducing anxiety and depression through counseling.²

Table: Effects of Lifestyle on Heart Health Level

Low Heart Health

Fair Heart Health

High Heart Health

Smoking

Currently smoking

Quit less than a year ago

Never smoked or quit more than a year ago

Healthy diet:

1 point for each:

• >4 servings of fruits and vegetables per day

• 2 or more servings of fish per wk

• >1500 mg of salt per day

• ≤450 calories per week of sweets

• ≥3 servings of whole grains per day

0 or 1 point

2 or 3 points

4 or 5 points

Exercise

No exercise

Up to 49 min a week at moderate intensity

≥150 min a week at moderate intensity

Body mass index

≥30 kg/m²

25-29.9 kg/m²

<25 kg/m²

Fasting blood glucose

≥126 mg/dL

100-125 mg/dL

<100 mg/dL

Total cholesterol (mg/dL)

(with treatment)

≥240 (>200)

200-239

(<200)

<200

Blood pressure

(with treatment)

Systolic: ≥140

Diastolic: ≥90

(>140/90)

Systolic: 120-139

Diastolic: 80-89

(<140/ 90)

<120/80

Adapted from reference 4.

Debra Freiheit has been a practicing pharmacist and human services professional for over 25 years. Specializing in medical information, Debra has compiled a broad spectrum of experience obtained through research for companies including Cerner and PPD Inc. With an emphasis on clear and concise information transfer, Debra has built a career communicating data with medical professionals and patients. Education and knowledge have been the motivation of a rich career of caregiving through research. Debra’s current project involves the creation of a multi-national database of drug information.

References

• Weibel L, Massarotto P, Hediger H, Mahrer-Imhof R. Early education and counselling of patients with acute coronary syndrome. A pilot study for a randomized controlled trial. Eur J Cardiovasc Nurs. 2014; pii: 1474515114556713.
• Shin ES, Hwang SY, Jeong MH, Lee ES. Relationships of factors affecting self-care compliance in acute coronary syndrome patients following percutaneous coronary intervention. Asian Nurs Res. 2013;7(4):205-211.
• Chrysant SG, Chrysant GS. The cardiovascular consequences of excess sitting time. J Clin Hypertens. 2015;17(7):528-531. doi: 10.1111/jch.12519.
• Chrysant SG, Chrysant GS. A healthy lifestyle could reduce the onset of first heart attack by 80. J Clin Hypertens. 2015;17(3):168-171. doi: 10.1111/jch.12466.
• De Caterina R, Husted S, Wallentin L, et al. New oral anticoagulants in atrial fibrillation and acute coronary syndromes: ESC Working Group on Thrombosis—Task Force on Anticoagulants in Heart Disease Position Paper. J Am Coll Cardiol. 2012;59(16):1413-1425. doi: 10.1016/j.jacc.2012.02.008.
• Kumar A, Cannon CP. Acute coronary syndromes: diagnosis and management, part I. Mayo Clin Proc. 2009:84(10):917-938.
• Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA. 2002;288(4):462-467. doi: 10.1001/jama.288.4.462.