title: Adherence to Cardiac Practice Guidelines in the Management of Non-ST-Elevation Acute Coronary Syndromes: A Systematic Literature Review.
abstract: BACKGROUND
  In the management of non-ST-elevation acute coronary syndrome (NSTACS) a gap between guideline-recommended care and actual practice has been reported. A systematic overview of the actual extent of this gap, its potential impact on patient-outcomes, and influential factors is lacking.
  
  
  OBJECTIVE
  To examine the extent of guideline adherence, to study associations with the occurrence of adverse cardiac events, and to identify factors associated with guideline adherence.
  
  
  METHODS
  Systematic literature review, for which PUBMED, EMBASE, CINAHL, and the Cochrane library were searched until March 2016. Further, a manual search was performed using reference lists of included studies. Two reviewers independently performed quality-assessment and data extraction of the eligible studies.
  
  
  RESULTS
  Adherence rates varied widely within and between 45 eligible studies, ranging from less than 5.0 % to more than 95.0 % for recommendations on acute and discharge pharmacological treatment, 34.3 % - 93.0 % for risk stratification, and 16.0 % - 95.8 % for performing coronary angiography. Seven studies indicated that higher adherence rates were associated with lower mortality. Several patient-related (e.g. age, gender, co-morbidities) and organization-related (e.g. teaching hospital) factors influencing adherence were identified.
  
  
  CONCLUSIONS
  This review showed wide variation in guideline adherence, with a substantial proportion of NST-ACS patients possibly not receiving guideline-recommended care. Consequently, lower adherence might be associated with a higher risk for poor prognosis. Future research should further investigate the complex nature of guideline adherence in NST-ACS, its impact on clinical care, and factors influencing adherence. This knowledge is essential to optimize clinical management of NSTACS patients and could guide future quality improvement initiatives.
authors.affiliation: EMGO Institute for Health and Care Research, Department of Public and Occupational Health, VU University Medical Center. Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands.
authors.forename: Josien
authors.initials: J
authors.lastname: Engel
authors.forename: Nikki L
authors.initials: NL
authors.lastname: Damen
authors.forename: Ineke
authors.initials: I
authors.lastname: van der Wulp
authors.forename: Martine C
authors.initials: MC
authors.lastname: de Bruijne
authors.forename: Cordula
authors.initials: C
authors.lastname: Wagner
mesh_terms: D054058:Acute Coronary Syndrome / Q000628:therapy*; D000789:Angina, Unstable / Q000628:therapy; D017023:Coronary Angiography; D019983:Guideline Adherence; D006801:Humans; D017410:Practice Guidelines as Topic