Initiation of Secondary Prevention Medications
for Myocardial Infarction using Technology-Assisted Pharmacist
Anthony Kessels, Pharm.D., BCPS, Thomas Bailey, M.D., Laura
Noirot, B.S., William C. Dunagan, M.D., Erin Rachmiel, Pharm.D.,
BCPS, Rina Shah, Pharm.D., BCPS,
St. Louis, Missouri
Secondary prevention guidelines for the treatment of coronary
artery disease have been well researched and established,
including the use of aspirin, β-adrenergic blocking agents,
angiotensin-converting enzyme inhibitors (ACE-I), and statins
to decrease the risk of subsequent cardiac events and death.
Despite well-documented evidence, an unacceptably low number
of patients are discharged on these therapies in the United
States. Studies have shown that in-hospital initiation of
secondary prevention medications increases outpatient compliance
and improves long-term outcomes. Recognizing this, a computerized
system to alert pharmacists of the need to review the medication
therapy of inpatients following an acute MI was designed and
implemented to increase adherence with the secondary prevention
Description of the Program
Data were initially gathered on the percentage of patients
at Barnes-Jewish Hospital discharged on appropriate post-myocardial
infarction (MI) medication therapy. At baseline, only 88%
of patients were prescribed aspirin, 71% β-blockers, 60% ACE-Is,
and 80% statins upon discharge. Additionally, only 67% of
patients had a lipid panel drawn within 24 hours of admission.
Based on the low percentage of patients discharged on optimal
medications, we designed a program to improve compliance with
secondary prevention guidelines by using a decision-support
application with pharmacist intervention.
Between February 2000 and May 2001, we conducted a preliminary
study to determine whether pharmacist intervention could increase
the proportion of patients discharged on an optimal medication
regimen in the post-MI period. We used a positive troponin
(> 1.4 mg/dL) within 24 hours of admission to identify
patients with acute MI. Study pharmacists then intervened
on two medicine teams to ensure that eligible patients were
initiated on appropriate post-MI medications. Two other medicine
teams served as the control group. This study demonstrated
substantial improvement in prescription rates of appropriate
post-MI medications with pharmacist intervention.
After demonstrating better adherence to guidelines among
patients in the intervention group, the program was expanded
to all patients with acute MI with troponins greater than
1.4 mg/dL. In addition, inpatient pharmacists were held accountable
for this intervention as part of their patient-care responsibilities.
Major implementation steps included the following:
- Establishing a real-time clinical process to identify
all patients with positive troponins.
- Performing lipid panels on all patients with elevated
- Developing a decision support system to evaluate post-MI
medications and valid contraindications.
- Implementing an intranet website to alert pharmacists
to patients’ demographic information, post-MI medication
regimens, and other pertinent information.
- Training pharmacy staff to communicate with physicians
to ensure that patients are started on appropriate medications
Experience with the Program
Average rates of discharge prescriptions are substantially
greater than original baseline percentages and have met targets
for all agents. Aspirin discharge prescription rates have
improved to a mean of 98%, β-blockers 98%, ACE-I 94%, and
statins 97%. In operation for over two years, the program
has maintained the improvement in the percentage of patients
discharged on an appropriate post-MI medication regimen.
A computerized system was successful in alerting pharmacists
to inpatients with acute MI, thereby facilitating communication
with physicians to ensure that appropriate post-MI medication
therapy could be initiated before discharge.