Navigating Critical Pathways: Ensuring Optimal Management of Acute Coronary Syndrome
Activity Date: August 2007  — Activity Info: Volume 4, (7)
Goals & Objectives | Faculty | Introduction | Full Activity Content | CME Test & Evaluation (CME Expired)

Navigating Critical Pathways: Ensuring Optimal Management of Acute Coronary Syndrome
Robert B. Parker, PharmD, FCCP*

Acute coronary syndrome (ACS) is an important source of morbidity and mortality in the United States and inflicts a heavy toll on the US healthcare system. Hospital discharges that had ACS listed as a diagnosis totaled more than 1.5 million in 2004,1 and ACS results in a nationwide average of $400 billion in healthcare costs within the first year of diagnosis.2 The prevalence of this condition has drawn deserved research attention, which has resulted in a rapidly shifting paradigm of best practices in ACS management. Clinicians involved in the care of individuals with ACS, including hospital pharmacists, require a practical knowledge of evidence-based guidelines, such as those developed by a joint panel representing the American College of Cardiology (ACC) and the American Heart Association (AHA),3,4 and the institutional framework within which they can achieve the highest level of care for their patients.

Despite the weight of evidence that supports current treatment recommendations, the care provided at many institutions is not consistent with evidence-based guidelines.5,6 Inappropriate prescribing habits in ACS have been identified as one important source of unnecessary complications. For instance, the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines registry reported that 42% of patients received at least 1 antithrombotic drug that was one dose higher than that recommended by ACC/AHA guidelines.6 Patients receiving higher doses of these agents, including unfractionated heparin, low-molecular weight heparin (LMWH), and glycoprotein IIb/IIIa inhibitors, experienced a higher risk of major bleeding that increased proportionately with excess dosing.6 Inappropriate anticoagulant prescribing habits have been identified as a critical issue that impacts outcomes in ACS. Consequently, the Joint Commission has proposed the inclusion of anticoagulant prescribing recommendations in its proposed National Patient Safety Goals and Requirements for 2008.7 As best practices in ACS care are often based on the appropriate use of pharmacotherapy, hospital pharmacists can play an important role in driving institutional change and ensuring that protocols reflect best practices in ACS.

Unique institutional protocols are the most effective way to ensure that best practices are routinely implemented in the care of complex conditions such as ACS. Critical pathways have been used as an effective strategy to streamline care and control treatment costs by facilitating the adoption of evidence-based treatment protocols. Pharmacists play a key role in the development and implementation of critical pathways that depend on pharmacologic treatments and therapeutic monitoring for conditions such as ACS. Furthermore, the American College of Clinical Pharmacy Task Force on Critical Pathways has recommended that services offered by pharmacists, including pharmacotherapy consults and discharge counseling, should be integrated into critical pathways that direct the treatment of conditions that require extensive pharmacologic support, including ACS.8 Hospital pharmacists could therefore benefit from a review of evidence-based treatment guidelines in ACS and the concept of critical pathways to support the standardization of care for this disease state.

Major initiatives to drive the adoption of standardized treatment protocols in ACS have resulted in improvements in care and support the concept of critical pathways in ACS. The ACC Acute Myocardial Infarction Guidelines Applied in Practice Project demonstrated that protocol support with a standardized tool kit of resources resulted in improved adherence to quality indicators and improved patient outcomes as measured by fewer rehospitalizations for heart problems, fewer myocardial infarction (MI) episodes, and fewer incidents of death, cerebrovascular accident, or MI for up to 6 months after discharge.9,10 The Global Registry of Acute Coronary Events tracked improved adherence to evidence-based treatment strategies over time, which was associated with significant improvements in the incidence of new heart failure, stroke, subsequent MI, and mortality in the 6 months following hospital discharge.11 However, researchers noted that improvement is still needed in longer-term outcomes and suggested the adoption of more aggressive in-hospital care and post-discharge support.12

Hospital pharmacists play an important role in the development and implementation of critical pathways in ACS. Standardized medication orders are common tools within the framework of critical pathways designed to streamline care, and pharmacists are responsible for drafting these institution-specific materials. Hospital pharmacists are responsible for ensuring appropriate therapeutic monitoring of medications used in ACS (eg, unfractionated heparin and LMWH) in order to avoid the possible complications arising from sub- or supertherapeutic doses.

In this issue of University of Tennessee  Advanced Studies in Pharmacy, hospital pharmacists who specialize in the management of ACS offer insight into the use of critical pathways to standardize care and improve patient outcomes. Paul P. Dobesh, PharmD, FCCP, BCPS, of the University of Nebraska, opens the discussion with an overview of current practices in ACS care, the urgent need for critical pathways, and the role of the hospital pharmacist in supporting the adoption of critical pathways in ACS. Judy W. M. Cheng, PharmD, MPH, BCPS, FCCP, of Mount Sinai Medical Center in New York, contributes an overview of clinical trials that support the use of standardized protocols in ACS to improve outcomes and reviews practical tools that are available to institutions interested in developing protocols and critical pathways for ACS. In the third article, Kerry K. Pickworth, PharmD, of the Ohio State University Medical Center, reviews the ACC/AHA evidence-based treatment guidelines for ACS that are reflected in successful critical pathways and the role of the hospital pharmacist in providing supportive care, including therapeutic monitoring and discharge instructions. Robert B. Parker, PharmD, FCCP, of the University of Tennessee, concludes the discussion with a case study that illustrates the effective management of ACS in clinical practice. After the completion of this educational monograph, hospital pharmacists should understand the importance of standardized, evidence-based care in ACS and the value of critical pathways in achieving improved patient outcomes.

1. Rosamond W, Flegal K, Friday G, et al. Heart disease and stroke statistics--2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2007;115:e69-e171.
2. Etemad LR, McCollam PL. Total first-year costs of acute coronary syndrome in a managed care setting. J Manag Care Pharm. 2005;11:300-306.
3. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA 2002 guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction--summary article: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002;40:1366-1374.
4. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA  guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82-e292.
5. Rogers WJ, Canto JG, Lambrew CT, et al. Temporal trends in the treatment of over 1.5 million patients with myocardial infarction in the U.S. from 1990 through 1999: the National Registry of Myocardial Infarction 1, 2 and 3. J Am Coll Cardiol. 2000;36:2056-2063.
6. Alexander KP, Chen AY, Roe MT, et al. Excess dosing of antiplatelet and antithrombin agents in the treatment of non-ST-segment elevation acute coronary syndromes. JAMA. 2005;294:3108-3116.
7. The Joint Commission. Potential 2008 National Patient Safety Goals and Requirements. Critical Access Hospital Version. Available at:
Accessed June 7, 2007.
8. Dobesh PP, Bosso J, Wortman S, et al. Critical pathways: the role of pharmacy today and tomorrow. Pharmacotherapy. 2006;26:1358-1368.
9. Mehta RH, Montoye CK, Faul J, et al. Enhancing quality of care for acute myocardial infarction: shifting the focus of improvement from key indicators to process of care and tool use: the American College of Cardiology Acute Myocardial Infarction Guidelines Applied in Practice Project in Michigan: Flint and Saginaw Expansion. J Am Coll Cardiol. 2004;43:2166-2173.
10. Vasaiwala S, Nolan E, Ramanath VS, et al. A quality guarantee in acute coronary syndromes: the American College of Cardiology’s Guidelines Applied in Practice program taken real-time. Am Heart J. 2007;153:16-21.
11. Fox KA, Steg PG, Eagle KA, et al. Decline in rates of death and heart failure in acute coronary syndromes, 1999-2006. JAMA. 2007;297:1892-1900.
12. Goldberg RJ, Currie K, White K, et al. Six-month outcomes in a multinational registry of patients hospitalized with an acute coronary syndrome (the Global Registry of Acute Coronary Events [GRACE]). Am J Cardiol. 2004;93:288-293.

*Professor, University of Tennessee, Department of Clinical Pharmacy, Memphis, Tennessee.
Address correspondence to: Robert B. Parker, PharmD, FCCP, Professor, University of Tennessee, Department of Clinical Pharmacy, 26 South Dunlap Street, Memphis, TN 38163.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.
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