Foreword

Abstract

Guidelines previously recommended use of dual antiplatelet therapy, statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) and beta blockers (five classes of drugs) in patients without contraindications or intolerance after acute coronary syndrome (ACS). However, recent guidelines have taken a more nuanced view regarding the use of ACEI/ARB and beta blockers. Our aim was to develop a composite post-discharge medication indicator, based on available evidence, to support quality improvement.4,112 consecutive post-ACS patients who underwent coronary angiography and left ventricular ejection fraction (LVEF) assessment in 2015–16 were recorded in the All New Zealand ACS Quality Improvement (ANZACS-QI) registry. Patients receiving coronary artery bypass grafting were excluded. Three composite indicator algorithms that took into account known contraindications/intolerances were compared across NZ District Health Boards (DHBs):1.Five-drug-class indicator: aspirin, a second antiplatelet agent, statin, ACEI/ARB and a beta blocker.2.An indicator based on the 2016 National Heart Foundation of Australia & Cardiac Society of NZ and Australia recommendations (NHFA/CSANZ indicator): aspirin, a second antiplatelet agent and a statin. Those with high-risk features (LVEF < 40%, clinical heart failure, anterior myocardial infarct, diabetes or hypertension) should receive an ACEI/ARB and those with LVEF < 40% a beta blocker.3.ANZACS-QI modified NHFA/CSANZ indicator: aspirin, a second antiplatelet agent, statin and an ACEI/ARB (four classes), and those with LVEF < 40% a beta blocker (five classes).Overall and individual DHB performance was highest (74%, DHB range 52–84%) when reported using the NHFA/CSANZ indicator, and slightly lower (69%, DHB range 48–78%) on the ANZACS-QI indicator. Performance was lowest using the older five-drug-class indicator (65%, DHB range 48–77%).We have developed a composite post-discharge medication indicator appropriate for use in identifying gaps in evidence-based management across NZ, which is now being reported regularly to DHBs.