Improving Communication With GPs Post-STEMI

JJ Coughlan; Conor Hickie; Barbara Gorna; Ross Murphy; Peter Crean

Disclosures

Br J Cardiol. 2016;23(4):138-140. 

In This Article

Abstract and Introduction

Abstract

The rationale behind secondary prevention post-ST-elevation myocardial infarction (STEMI) is well established. Guidelines recommend titration of several medications for secondary prevention up to a maximally tolerated dose in order to confer maximum benefit. Due to decreasing duration of inpatient stays post-myocardial infarction (MI), this up-titration must often take place in primary care. Guidelines also recommend clearly informing GPs regarding duration of dual antiplatelet therapy and monitoring cardiovascular risk factors. Clear communication between secondary/tertiary and primary healthcare practitioners is essential in order to ensure our patients are receiving optimum care.

We examined all discharge summaries for patients discharged post-STEMI in our tertiary referral centre. This encompassed rates of prescribing of the National Institute for Health and Care Excellence (NICE) recommended medications post-MI, rates of therapeutic prescribing of these medications and communication with GPs regarding duration of dual antiplatelet therapy, up-titration of medications and repeat checking of fasting lipid profiles. In order to improve compliance with guidelines, incoming junior staff were educated on guidelines for communication post-STEMI at our journal club. We then re-audited our practice in order to see if compliance with the guidelines improved.

Our results showed that, while the majority of our patients were discharged on the correct medications post-MI, most were receiving subtherapeutic doses of angiotensin-converting enzyme (ACE) inhibitors and beta blockers. In addition, we exhibited poor communication with primary healthcare practitioners. Compliance with the NICE guidelines on communication significantly improved after our intervention.

In conclusion, education of junior staff can significantly improve communication with GPs. This, in turn, could help optimise secondary prevention strategies post-MI.

Introduction

Coronary artery disease remains one of the leading causes of death in Ireland,[1] the UK,[2] and worldwide. Despite advances in management, it is a major source of morbidity and mortality in our healthcare system. Numerous trials (PROVE-IT,[3] ISIS-1,[4] ISIS-2,[5] ISIS-3,[6] ISIS-4,[7] AIRE,[8] CAPRICORN[9]) have established the prognostic benefits associated with adequate secondary prevention post ST-elevation myocardial infarction (STEMI).

National Institute for Health and Care Excellence (NICE) guidelines[10] recommend all patients discharged post-STEMI should be offered treatment with an angiotensin-converting enzyme inhibitor (ACEi), beta blocker (BB), dual antiplatelet therapy (DAPT) and a statin. The evidence for these medications is based on trials in which the drugs were used at high doses. The benefit at lower doses is not clear and best practice dictates titrating medications up to the maximally tolerated dose. This has been shown to reduce morbidity and mortality for these patients, reducing recurrent hospital admissions, re-infarction and death.[3–9]

The guidelines[10] also state that patients should be discharged with clear information for their general practitioner (GP) regarding incomplete dose titrations and plans for antiplatelet and anticoagulant treatment.

Clear instructions are essential, as GPs may be reluctant to make changes to medications prescribed by specialists. Given many medications cannot be up-titrated to maximally tolerated doses during brief inpatient stays,[11] the GP plays a key role in ensuring this is done as an outpatient.

If the medication is not titrated up to the maximally tolerated dose, the patient may not derive maximum benefit and may suffer an increased risk of major adverse cardiac events (MACEs).

We hope that a focus on improved communication will lead to improved clinical outcomes, patient experience and continuity of care between primary and secondary or tertiary care services.

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