Room for Improvement in Acute Coronary Syndrome Treatment

Antithrombotic therapy is an essential element of treatment after patients experience acute coronary syndrome (ACS). Fortunately, prescribers can draw from a considerably larger selection of antithrombotics than ever before, as prasugrel, ticagrelor, fondaparinux, and bivalirudin have joined warfarin, unfractionated heparin, and the low molecular weight heparins in evidence-based guidelines.

In a study published online January 2, 2015, in European Heart Journal: Acute Cardiovascular Care, a multinational team of researchers looked at international patterns of antithrombotic therapy in patients hospitalized for ACS, focusing on both the pre- and in-hospital periods. They also looked for opportunities to improve ACS care.

Using the international EPICOR (long-tErm follow-uP of antithrombotic management patterns in acute CORonary syndrome patients) cohort study data, the researchers examined care in 10,568 consecutive ACS survivors from 555 hospitals in 20 countries across Europe and Latin America. The study was conducted between September 2010 and March 2011.

Before hospitalization, only 44.8% of the ACS patients received care: 40% had an electrocardiogram, 20% received antiplatelet therapy, and 101 ST-segment elevation myocardial infarction (STEMI) patients (2%) received fibrinolysis. The researchers indicated that pre-hospitalization care is the area that could be most improved due to low pre-hospital use of antithrombotic drugs.

During hospitalization, 75% of patients received dual antiplatelet therapy. Clopidogrel was most often prescribed to patients (69.7%), while prasugrel (5.4%) was prescribed least often.

Approximately 16% received triple antiplatelet therapy, and 8% were prescribed single antiplatelet therapy.

STEMI patients were significantly more likely to receive prehospital antithrombotics, with prasugrel, glycoprotein IIb/IIIa inhibitors (abciximab, tirofiban, eptifibatide), and unfractionated heparin received more frequently in-hospital. On the other hand, non-ST-segment elevation ACS patients were significantly more likely to receive clopidogrel, single antiplatelet therapy, and fondaparinux.

As many as 33% of ACS patients were medically managed.

The authors found that physicians were very likely to comply with guideline recommendations to use dual antiplatelet therapy early in ACS, regardless of the initial strategy employed. Although roughly 95% of patients received a P2Y₁₂ inhibitor, the researchers noted that uptake of prasugrel—the only new P2Y₁₂ inhibitor available during the study period—was slow and varied geographically, often due to cost constraints. Thus, they urged better compliance with ACS treatment guidelines.