Elsevier

International Journal of Cardiology

Volume 318, 1 November 2020, Pages 14-20
International Journal of Cardiology

Better adherence with out-of-hospital healthcare improved long-term prognosis of acute coronary syndromes: Evidence from an Italian real-world investigation

https://doi.org/10.1016/j.ijcard.2020.06.017Get rights and content

Highlights

  • The risk of CV disease was 37% at 5 years since index discharge for ACS.

  • 80% of patients used selected drugs, underwent ECG and lipid profile examination.

  • One patient on five underwent cardiac rehabilitation.

  • Cardiovascular risk was affected by adherence to recommendations.

Abstract

Background

Patients who experience a hospital admission for acute coronary syndromes (ACS) exhibit poor prognosis over the years. The purposes of this study were to evaluate the real-world patterns of out-of-hospital practice in the management of ACS patients and to assess their impact on the risk of selected outcomes.

Methods

The cohort of 87,530 residents in the Lombardy Region (Italy) who were newly hospitalised for ACS during 2011–2015 was followed until 2018. Exposure to medical treatment including use of selected drugs, diagnostic procedures and laboratory tests was recorded. The main outcome of interest was re-hospitalisation for cardiovascular (CV) outcomes. Proportional hazards models were fitted to estimate hazard ratio, and 95% confidence intervals (CI), for the exposure-outcome association. Analyses were stratified according to the ACS type.

Results

The cumulative incidence of re-hospitalisation for CV disease was 33%, 42% and 38% at 5 years after index discharge among STEMI, NSTEMI and unstable angina patients. Within one year from index discharge, between 70% and 80% of patients had at least a prescription of statins, beta-blockers and renin–angiotensin-system blocking agents, underwent ECG and lipid profile examination, and had a cardiologic examination. One patient in five underwent cardiac rehabilitation. Compared with patients who did not adhere to healthcare recommendations, the risk of CV hospital readmission was reduced from 10% (95% CI: 4%–10%) to 23% (12%–32%) among patients who underwent lipid profile examinations and who experienced cardiac rehabilitation.

Conclusion

Close out-of-hospital healthcare must be considered the cornerstone for improving the long-term prognosis of ACS patients.

Introduction

Acute coronary syndromes (ACS), or “heart attacks”, include unstable angina and acute myocardial infarction with and without ST elevation (STEMI and NSTEMI, respectively) [[1], [2], [3]]. Mortality from ACS has declined substantially in most developed countries [4,5]. In Italy, during the Nineties almost two-thirds of the decrease in coronary mortality was due to the reduction in 28-day case-fatality [6], probably because, in the same period, impressive improvements took place in medical treatment [7]. This means that, with respect to the last few decades, many more patients now survive acute heart attacks, and their management after hospital discharge has become a major challenge for improving long-term prognosis [8].

The purpose of the present large real-world study was to evaluate the relationship between the healthcare patterns supplied to a cohort of patients who experienced their first episode of acute ACS and selected clinical outcomes, including rehospitalisation and death.

Section snippets

Setting

The data used for this study were retrieved from the healthcare utilisation databases of Lombardy, an Italian Region that accounts for about 16% (almost ten million) of the national population. In Italy, the whole population is covered by the National Health Service (NHS), and in Lombardy this has been associated since 1997 with an automated system of databases that collect a variety of information, including at least: (i) demographic and administrative data on residents who receive NHS

Patients

The distribution of the exclusion criteria is shown in Supplementary Fig. S1. Among the 85,429 patients included in the first cohort, 38,711, 30,673 and 16,045 had a STEMI, NSTEMI and unstable angina diagnosis, respectively. Their baseline characteristics are shown in Table 1. The mean age was about 70 years and 65% of patients were men. With respect to patients with unstable angina, and to an even greater extent to those with NSTEMI, cohort members with STEMI were younger, were more often men,

Discussion

Our study showed that four in ten of the 85,429 patients who were discharged alive from their first hospitalisation for ACS experienced a readmission for any CV disease within just over six years. This confirms the results of previous studies [8,[21], [22], [23]] showing a high rate of CV events and long-term poor prognosis after hospital discharge, suggesting that secondary prevention is of paramount importance in this setting [24,25]. Our study adds to the previous results that patients with

Conclusion

Because benefits for patients and the healthcare system are expected by improving adherence to guideline-driven recommendations, close out-of-hospital healthcare for ACS patients must be considered the cornerstone for obtaining clinical and perhaps economic benefits.

The following are the supplementary data related to this article.

. Flow-chart of inclusion and exclusion criteria. Footnote. Three cohorts were selected for estimating (i) outcome onset (first cohort), (ii) the first-year use of

Funding

This study was supported by grants from the Italian Ministry of the Education, University and Research (’Fondo d'Ateneo per la Ricerca’ portion, year 2018), and from the Italian Ministry of Health (‘Ricerca Finalizzata 2016’, NET- 2016-02363853). The funding sources had no role in the design of the study, the collection, analysis and interpretation of the data, or the decision to approve publication of the finished manuscript.

Ethical issues

The Ethical Committee of the University of Milano-Bicocca evaluated the protocol and established that the study (i) was exempt from informed consent (according to General Authorization for the Processing of Personal Data for Scientific Research Purposes Issued by the Italian Privacy Authority on December 15, 2016; http://www.garanteprivacy.it/web/guest/home/docweb/-/docweb-display/docweb/5805552) (ii) provides sufficient guarantees of individual records anonymity, and (iii) was designed

Declaration of Competing Interest

Giovanni Corrao received research support from the European Community (EC), the Italian Agency of Drug (AIFA), and the Italian Ministry of Education, University and Research (MIUR). He took part to a variety of projects that were funded by pharmaceutical companies (i.e., Novartis, GSK, Roche, AMGEN and BMS). He also received honoraria as member of Advisory Board from Roche.

For the remaining authors, nothing was declared.

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