Abstract
Implementation of a critical care pathway (CCP) for acute coronary syndrome (ACS) has been shown to improve early compliance to guideline-directed therapies and reduce early mortality. Nevertheless its long-term impact on the compliance with medications or clinical outcomes remains unknown. Between 2004 and 2015, 2023 consecutive patients were admitted to our coronary care unit with ACS. We retrospectively compared the outcomes of 628 versus 1059 patients (mean age 66.1 ± 13.3 years, 74% male) managed before and after full implementation of a CCP. Compared with standard care, implementation of the CCP significantly increased coronary revascularization and long-term compliance with guideline-directed medical therapy (both P < 0.01). After a mean follow-up of 66.5 ± 44.0 months, 46.7% and 22.2% patients admitted before and after implementation of the CCP, respectively, died. Kaplan-Meier analyses showed that patients managed by CCP had better overall survival (P = 0.03) than those managed with standard care. After adjustment for clinical covariates and coronary anatomy, CCP remained independently predictive of better survival from all-cause mortality [hazard ratio (HR): 0.75, 95%confidence intervals (CI): 0.62–0.92, P < 0.01]. Stepwise multivariate cox regression model showed that both revascularization (HR: 0.55, 95%CI: 0.45–0.68, P < 0.01) and compliance to statin (HR: 0.70, 95%CI: 0.58–0.85, P < 0.01) were accountable for the improved outcome.
Highlights
628 patients admitted during the pre-critical care pathway (CCP) period and 1059 patients admitted during the post-CCP period who survived to hospital discharge were included in the final analysis
Patients admitted after implementation of the CCP shared similar baseline characteristics with those admitted before implementation of the CCP, except that more patients in the former group had a history of hypertension and fewer patients had chronic kidney disease
We showed that higher rate of revascularization (HR 0.55, 95% confidence intervals (CI): 0.45–0.68, P < 0.01), compliance to statin (HR 0.70, 95% CI: 0.58–0.85, P < 0.01) and improved low density lipoprotein-cholesterol (LDL-C) at follow-up (HR 1.14, 95% CI: 1.02–1.26, P = 0.02) were accountable for the improved outcome (Table 3)
Summary
Long-term compliance to a guideline-directed medical therapy was defined prescription of a medication at discharge and follow-up visits with a medication possession ratio (i.e. the proportion of patients’ time on the drug) ≥ 80% at one year for clopidogrel, and at the last follow-up visit for statin, betablocker and ACEI/ARB19,31. I, n (%) II, n (%) III, n (%) IV, n (%) Smoker, n (%) Past medical history Hypertension, n (%) Diabetes mellitus, n (%) Hyperlipidemia, n (%) ACS, n (%) Chronic kidney disease, n (%) Baseline LDL-C (mmol/L) LVEF at one month ≥50%, n (%) 36–49%, n (%) ≤35%, n (%) Creatine kinase (IU/L) Coronary angiography Left main disease, n (%) Triple vessel disease, n (%) Revascularization, n (%) Bare metal stents, n (%) Implantable cardioverter defibrillator, n (%) Cardiac rehabilitation, n (%) Long-term compliance with medications Clopidogrel, n (%) Statin, n (%) Betablocker, n (%) ACEI/ARB, n (%) Follow-up LDL-C (mmol/L) Follow-up LVEF ≥50%, n (%) 36–49%, n (%) ≤35%, n (%)
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