Optimal medical therapy for non-ST-segment-elevation acute coronary syndromes: exploring why physicians do not prescribe evidence-based treatment and why patients discontinue medications after discharge.
BACKGROUND
Acute coronary syndrome (ACS) patients in the highest risk categories are least likely to receive evidence-based treatments (EBTs). We sought to determine why physicians do not prescribe EBTs for patients with non-ST-segment-elevation ACSs and the factors determining use of these treatments after 1 year.


RESULTS
One thousand nine hundred fifty-six non-ST-segment-elevation ACS patients were enrolled in the prospective, multicenter Canadian ACS registry II between October 2002 and December 2003. Each patient's physician gave reasons why guideline-indicated medication(s) was not prescribed during hospitalization. Medication use and reason(s) for discontinuation after 1 year were obtained by telephone interview of the patients. The commonest reason for not prescribing EBTs was "not high-enough risk" or "no evidence/guidelines to support use." However, Global Registry of Acute Coronary Events scores of patients not treated for this reason were often similar to or higher than those of patients prescribed such treatment. After 1 year, 77% of patients not on optimal ACS treatment at discharge remained without optimal treatment, and overall antiplatelet, β-blocker, and angiotensin-converting enzyme inhibitor use declined. Approximately one third of patients not taking EBTs had stopped their medication without instruction from their doctor.


CONCLUSIONS
Nonprovision of EBTs may be due to subjective underestimation of patient risk and hence, likely treatment benefit. Oversights in care delivery were also apparent. Objective risk stratification, combined with efforts to ensure provision and adherence to EBTs, should be encouraged.
Bagnall
Alan J
AJ
Department of Cardiology, The Freeman Hospital, Newcastle Upon Tyne, Tyne and Wear, UK.
Yan
Andrew T
AT
Yan
Raymond T
RT
Lee
Cindy H
CH
Tan
Mary
M
Baer
Carolyn
C
Polasek
Petr
P
Fitchett
David H
DH
Langer
Anatoly
A
Goodman
Shaun G
SG
D054058:Acute Coronary Syndrome / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology; D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000368:Aged; D003661:Decision Support Techniques; D019317:Evidence-Based Medicine; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D010351:Patient Discharge; D010361:Patients; D010820:Physicians; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D055656:Prescriptions / Q000706:statistics & numerical data*; D011446:Prospective Studies; D018570:Risk Assessment; D055502:Secondary Prevention / Q000639:trends
D000319:Adrenergic beta-Antagonists; D010975:Platelet Aggregation Inhibitors