GPs vital for secondary prevention in acute coronary syndromes

Published in Health News and Evidence

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Of the estimated 10 000 ACS-related deaths in 2010 approximately 5000 were because of a repeat myocardial infarction. Prevention of secondary events is essential for the health and welfare of the estimated 50 000 people who suffer from heart attacks each year in Australia. Health professionals working in primary care have a vital role to play in secondary prevention by ensuring patients are supported in the short and long term after a heart attack.

Practice points

  • Identify local secondary prevention / cardiac rehabilitation services and urge patients to attend sessions.
  • Ensure all of your patients who have experienced a recent heart attack or episode of unstable angina, and have been recently discharged from hospital, have started the appropriate secondary prevention medications.
  • Ensure patients have a heart attack action plan and understand it fully.
  • Counsel patients on the importance of medication adherence and ensure regular follow-ups, which should include monitoring of blood pressure and lipids. Continue management of lifestyle risk factors; encourage smoking cessation, increased physical activity, healthy eating, safe alcohol consumption and weight management.
  • Consider a psychosocial assessment, including depression, for all recent heart attack patients and whether they have adequate social support. Consider referral as appropriate.

Coronary heart disease: the cost of secondary events

Acute coronary syndromes (ACS) are acute episodes of myocardial infarction (MI) or unstable angina resulting from coronary heart disease (CHD) which results in an acute reduction in blood flow to the myocardium.1 MI is further defined by ST-segment changes on the ECG which indicates how much of the myocardium is being affected.1 MI with ST-segment elevation (STEMI) is considered more severe than MI either without ST-segment elevation or with ST-segment depression (NSTEMI).1 In 2010 there were an estimated 75 000 episodes of ACS in Australia, resulting in 10 000 deaths and an estimated cost to the economy of $5 billion.1 Around one third of the financial cost of ACS events is due to repeat events.

Around one-third of all ACS events and 50% of ACS-related deaths in Australia are secondary events.1 Patients who have had an ACS event have a high risk of a secondary event within 12 months. For patients with a diagnosis of MI: 1 in 11 will die and 1 in 9 will have a repeat MI within a year of their index event.2 Repeat events are also associated with higher mortality rates than initial events.1 This situation is improving; increasing uptake of evidence-based practice in the management of ACS has resulted in a reduction in the number of repeat events and deaths in ACS patients.3 However, gaps still remain and ACS patients require comprehensive secondary prevention measures to help reduce morbidity and mortality.

Secondary prevention in primary care

The George Institute recently outlined an ideal program for secondary prevention in ACS4 which encompassed four pillars:

  • Assessment of individual needs including psychosocial assessments and identification of literacy and linguistic barriers.
  • The provision of basic heart health information to patients.
  • Individual risk management including addressing biomedical, behavioural and psychosocial risk factors that might increase a patient’s chance of a secondary event as well as ensuring that patients are prescribed the appropriate medicines and understand how to take them.
  • Reassessment and ongoing support.

The management of ACS usually requires specialist care in a hospital  with ready access to surgical intervention. Problems may arise with transitional care arrangements when a patient is transferred from hospital back into primary care. In Australia the discharge management of patients with ACS has been identified as an area for improvement.5,6 In particular, prescribing therapeutic interventions as recommended by guidelines, providing patient education on cardiovascular risk factors and referring patients with ACS to secondary prevention programs are key.5,6 In addition effective communication of management plans and discharge summaries to the GP and to patients or carers have been identified as particular problems.5,6 In one study about 20% of patients did not have a discharge summary forwarded to their GP and only 68% of GPs rated the information in the summaries they received as ‘very good’ to ‘excellent’.5

The primary care guide to secondary prevention in ACS

The goal of secondary prevention in ACS is to prevent recurrence of cardiovascular events, progression of cardiovascular disease and cardiovascular complications that commonly follow ACS.4 The George Institute has recognised that the GP should play a central role in coordinating care of patients after an MI.4

Ways GPs can help

Be aware of current guidelines

Unless contraindicated start all patients on aspirin, a second antiplatelet (such as clopidogrel, prasugrel, ticagrelor – for more information see NPS RADAR articles on ticagrelor and dual antiplatelet therapy), a β blocker, angiotensin-converting enzyme (ACE) inhibitor and a statin.7,8 There are still significant in-hospital treatment practice gaps with a proportion of patients not treated according to guidelines (Figure 1).3,5 If a patient has not been prescribed one of the indicated medicines at discharge, investigate further by liaising with the treating specialists as appropriate and prescribing appropriate medicines as necessary.

All patients should be  prescribed a short-acting nitrate and provided with a written action plan for chest pain to follow.8 Action plans and fact sheets are available from the National Heart Foundation.

Ensure adherence

Many ACS medicines are required for an extended period, or for life.1 Analysis of adherence to cardiovascular medicines in Australia shows that up to 25% of patients stop taking them after 6 months, and up to 47% of patients stop after two years.1,9 Barriers to adherence may occur if the condition is asymptomatic, if there is inadequate follow-up or discharge planning, a lack of patient education, complex treatment or side effects.10 Studies have confirmed a positive relationship between poor adherence and long-term mortality after acute MI.11 Premature cessation of antiplatelet therapy has been associated with increased risk of secondary events.12 Explain to patients taking dual antiplatelet therapy (aspirin and a second antiplatelet agent such as clopidogrel, prasugrel or ticagrelor) that they may experience bleeding and that this is normal. One study showed that up to 28% of patients taking dual antiplatelet therapy experienced nuisance bleeding and around 5% of these people stopped one or both therapies, a significantly higher stopping rate than in patients who did not experience nuisance bleeding.13

  • Advise patients of the importance of good medication adherence.
  • Be proactive in side effect management by explaining potential side effects when patients start a new medicine and ask patients if they have experienced side effects when they are reviewed.10

Enrol patients in a secondary prevention or cardiac rehabilitation program

Cardiac rehabilitation is effective in the prevention of secondary events and provides ongoing support in terms of managing modifiable risk factors and optimising pharmaceutical management.1 In Australia only about 60% of patients are referred to cardiac rehabilitation programs and less than 40% of these complete the programs (Figure 1).5 Patients report the reason they do not complete the program is that they feel that they are unnecessary or not suitable.5

Educating patients about the proven benefits of participating in secondary prevention or cardiac rehabilitation programs, and the risks to their health if they do not, may encourage more to complete the programs. For more information about programs in your area contact the Australian Cardiac Rehabilitation Association.

Evidence-practice gap

Figure 1. The evidence–practice gap in secondary prevention in ACS.3,5
Medicine use statistics 2006–2007, GRACE registry data on patients diagnosed with ACS without ST-elevation.

Consider psychosocial factors

Depression is common after an MI and patients with major depression or elevated depressive symptoms have a worse prognosis.8 Depression is also associated with poorer adherence and decreased chances of successful lifestyle modification.8

The National Heart Foundation8 recommends that all patients with MI be assessed for depression using a validated assessment tool and managed accordingly by referral to appropriate services and pharmacological management. Selective serotonin reuptake inhibitors are safe and effective in patients with coronary heart disease. Do not prescribe tricyclic antidepressants because of their antiarrhythmic effects.

Actively engage in lifestyle management counselling and patient education

Most cardiac rehabilitation programs include management of lifestyle risk factors. However, given the low number of patients completing programs it is important that GPs and other health professionals working in primary care reinforce the secondary prevention messages. Emphasise the need for weight management, cholesterol management, facilitation of smoking cessation and management of comorbidities such as diabetes.1,8

Patient education and communication is vital. Up to 50% of patients report that they have not been given treatment goals, treatment choices or self management plans, and that they received no explanation of medicine side effects.9 Patient education about the potential for certain side effects and the risks associated with non-adherence can help remove unnecessary barriers to treatment and may be important in ensuring patients remain on therapy and reduce their chance of secondary events.

  1. Access Economics. ACS in perspective. The importance of secondary prevention. 2011. (accessed 13 February 2013)
  2. Chew DP, Amerena JV, Coverdale SG, et al. Invasive management and late clinical outcomes in contemporary Australian management of acute coronary syndromes: observations from the ACACIA registry. Med J Aust 2008;188:691–7. [Pubmed]
  3. Aliprandi-Costa B, Ranasinghe I, Chow V, et al. Management and outcomes of patients with acute coronary syndromes in Australia and New Zealand, 2000-2007. Med J Aust 2011;195:116–21. [Pubmed]
  4. The George Institute. National Secondary Prevention of Coronary Disease Summit. 2012. 12 February 2013)
  5. Peterson GM, Thompson A, Pulver LK, et al. Management of acute coronary syndromes at hospital discharge: do targeted educational interventions improve practice quality? J Healthc Qual 2011. [Pubmed]
  6. Wai A, Pulver LK, Oliver K, et al. Current discharge management of acute coronary syndromes: baseline results from a national quality improvement initiative. Intern Med J 2012;42:e53–9. [Pubmed]
  7. Bezzina AJ. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006;185:294; author reply -5. [Pubmed]
  8. Heart Foundation. Reducing risk in heart disease. 2012. (accessed  25 February 2013).
  9. Australian Institute of Health and Welfare. Medicines for cardiovascular health: are they used appropriately? Cardiovascular disease series number 27. 2007. (accessed 13 February 2013)
  10. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487–97. [Pubmed]
  11. Rasmussen JN, Chong A, Alter DA. Relationship between adherence to evidence-based pharmacotherapy and long-term mortality after acute myocardial infarction. JAMA 2007;297:177–86. [Pubmed]
  12. Boggon R, van Staa TP, Timmis A, et al. Clopidogrel discontinuation after acute coronary syndromes: frequency, predictors and associations with death and myocardial infarction--a hospital registry-primary care linked cohort (MINAP-GPRD). Eur Heart J 2011;32:2376–86. [Pubmed]
  13. Ben-Dor I, Torguson R, Scheinowitz M, et al. Incidence, correlates, and clinical impact of nuisance bleeding after antiplatelet therapy for patients with drug-eluting stents. Am Heart J 2010;159:871–5. [Pubmed]