Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq

Keywords: Acute Coronary Syndrome, Professional Practice, Guideline Adherence, Drug Utilization, Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Antagonists, Clinical Audit, Iraq


Background: Optimal prescribing of secondary prevention medications after acute coronary syndrome (ACS) events has been shown to reduce morbidity and mortality. However, it is unknown whether these medications are optimally prescribed at discharge from acute care in Iraq.

Objective: To evaluate whether patients with ACS received optimal secondary prevention medications: antiplatelets, statins, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARBs), and beta-blockers at discharge from a cardiology unit, and to assess whether statins, ACEI/ARBs and beta-blockers were prescribed at target doses based on the American Heart Association/American College of Cardiology (AHA/ACC) guidelines.

Methods: Observational retrospective cross-sectional study of patients with ACS admitted to a hospital in Baghdad and survived to discharge between May 2016 and January 2017. Patient-level data and secondary prevention medications at discharge were extracted from routine medical records. Optimal dosing was defined as ≥75%, moderate dosing as 50–74%, and low dosing as <50% of the target dose.

Results:  45.6% (200/439) of eligible patients were included in the study who were aged 25 to 90 years (mean 57.8 years) with 78.0% (156/200) being male. Of those included, 84.5% had a myocardial infarction and 15.5% unstable angina, and the length of hospital stay ranged from 1 to 29 days (median 4 days).  In total, 53.5% of patients were prescribed all five secondary prevention medications at discharge, and after accounting for contraindications, 60.0% were treated according to AHA/ACC guidelines. The prescription rate of dual antiplatelet therapy, statins, ACEI/ARBs and beta-blockers was 92.5%, 94.5%, 69.5% and 87.0% respectively. Hypertension, diabetes mellitus and the prescription of oral nitrates were associated with the prescription of optimal secondary prevention therapy. Although 80.9% of patients were prescribed target doses of antiplatelets and statins, only 12.2% and 9.2% were prescribed target doses of ACEI/ARBs, and beta-blockers respectively.

Conclusions: Approximately one in two patients received the recommended secondary prevention therapy. However, only a minority of patients were prescribed optimal doses of ACEI/ARBs and beta-blockers, in line with guidance. Quality improvement strategies should be implemented, which may include greater involvement of pharmacists within the cardiology multidisciplinary team.


Download data is not yet available.


Isma'eel H, Mohanna Z, Hamadeh G, Alam E, Badr K, Alam S, Rebeiz A. The public cost of 3 statins for primary prevention of cardiovascular events in 7 Middle East countries: not all of them can afford it. Int J Cardiol. 2012;155(2):316-318. https://dx.doi.org/10.1016/j.ijcard.2011.12.011

Government of Iraq, Ministry of Health in collaboration with World Health Organization. Chronic non-communicable diseases risk factors survey in Iraq. Available at: http://www.who.int/chp/steps/IraqSTEPSReport2006.pdf (accessed May 23, 2018).

World Health Organization. Noncommunicable diseases (NCD) country profiles, Iraq. Available at: http://www.who.int/nmh/countries/irq_en.pdf (accessed June 26, 2018).

Choi E, Byeon H, Yang Y. Optimal medical therapy for secondary prevention after an acute coronary syndrome: 18-month follow-up results at a tertiary teaching hospital in South Korea. Ther Clin Risk Manag. 2016;12:167-175. https://dx.doi.org/10.2147/TCRM.S99869

Sheikh-Taha M, Hijazi Z. Evaluation of proper prescribing of cardiac medications at hospital discharge for patients with acute coronary syndromes (ACS) in two Lebanese hospitals. Springerplus. 2014;3:159. https://dx.doi.org/10.1186/2193-1801-3-159

Jan S, Lee SW, Sawhney JP, Ong TK, Chin CT, Kim HS, Krittayaphong R, Nhan VT, Itoh Y, Huo Y. Catastrophic health expenditure on acute coronary events in Asia: a prospective study. Bull World Health Organ. 2016;94(3):193-200. https://dx.doi.org/10.2471/BLT.15.158303

Roger VL, et al. Heart disease and stroke statistics--2012 update: a report from the American Heart Association. Circulation. 2012;125(1):e2-e220. https://dx.doi.org/10.1161/CIR.0b013e31823ac046

Tra J, van der Wulp I, Appelman Y, de Bruijne MC, Wagner C. Adherence to guidelines for the prescription of secondary prevention medication at hospital discharge after acute coronary syndrome: a multicentre study. Neth Heart J. 2015;23(4):214-221. https://dx.doi.org/10.1007/s12471-015-0664-y

Halvorsen S, Jortveit J, Hasvold P, Thuresson M, Oie E. Initiation of and long-term adherence to secondary preventive drugs after acute myocardial infarction. BMC Cardiovasc Disord. 2016;16:115. https://dx.doi.org/10.1186/s12872-016-0283-6

Becerra V, Gracia A, Desai K, Abogunrin S, Brand S, Chapman R, García Alonso F, Fuster V, Sanz G. Cost-effectiveness and public health benefit of secondary cardiovascular disease prevention from improved adherence using a polypill in the UK. BMJ Open. 2015;5(5):e007111. https://dx.doi.org/10.1136/bmjopen-2014-007111

Arnold SV, Spertus JA, Masoudi FA, Daugherty SL, Maddox TM, Li Y, Dodson JA, Chan PS. Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction. J Am Coll Cardiol. 2013;62(19):1791-1801. https://dx.doi.org/10.1016/j.jacc.2013.04.102

Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326(7404):1419. https://dx.doi.org/10.1136/bmj.326.7404.1419

O'Gara PT, Kushner FG, Ascheim DD, Casey DE Jr, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. https://dx.doi.org/10.1016/j.jacc.2012.11.019

Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ; ACC/AHA Task Force Members; Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;130(25):2354-2394. https://dx.doi.org/10.1161/CIR.0000000000000133

Pedersen SB, Nielsen JC, Botker HE, Goldberger JJ. Beta-blocker therapy early after myocardial infarction: a comparison between medication at hospital discharge and subsequent pharmacy-dispensed medication. Drugs Real World Outcomes. 2016;3(3):279-288. https://dx.doi.org/10.1007/s40801-016-0079-0

Grall S, Biere L, Le Nezet M, Bouvier JM, Lucas-Chauvelon P, Richard C, Abi-Khalil W, Delepine S, Prunier F, Furber A. Relationship between beta-blocker and angiotensin-converting enzyme inhibitor dose and clinical outcome following acute myocardial infarction. Circ J. 2015;79(3):632-640. https://dx.doi.org/10.1253/circj.CJ-14-0633

National Institute for Health and Care Excellence, NICE guidelines [CG172]. Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease. Available at: https://www.nice.org.uk/guidance/CG172/chapter/1-Recommendations#drug-therapy-2 (accessed May 3, 2018).

Smith MB, Lee NJ, Haney E, Carson S. Drug Class Review: HMG-CoA Reductase Inhibitors (Statins) and Fixed-dose Combination Products Containing a Statin: Final Report Update 5. Available at: http://www.ncbi.nlm.nih.gov/books/NBK47273/pdf/Bookshelf_NBK47273.pdf (accessed Jul 3, 2018).

Chung SC, Gedeborg R, Nicholas O, James S, Jeppsson A, Wolfe C, Heuschmann P, Wallentin L, Deanfield J, Timmis A, Jernberg T, Hemingway H. Acute myocardial infarction: a comparison of short-term survival in national outcome registries in Sweden and the UK. Lancet. 2014;383(9925):1305-1312. https://dx.doi.org/10.1016/S0140-6736(13)62070-X

Al-Zakwani I, Sulaiman K, Za’abi M, Panduranga P, Al-Habib K, Asaad N, Al Motarreb A, Hersi A, Al Faleh H, Al Saif S, Almahmeed W, Amin H, Alsheikh-Ali A, Al Lawati J, Al Suwaidi J. Impact of evidence-based cardiac medications on short and long-term mortality in 7,567 acute coronary syndrome patients in the Gulf RACE-II registry. Int J Clin Pharmacol Ther. 2012;50(6):418-425. https://dx.doi.org/10.5414/CP201667

Cannon CP, Braunwald E, McCabe CH, Rader DJ, Rouleau JL, Belder R, Joyal SV, Hill KA, Pfeffer MA, Skene AM; Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 Investigators. Intensive versus moderate lipid lowering with statins after acute coronary syndromes. N Engl J Med. 2004;350(15):1495-1504. https://dx.doi.org/10.1056/NEJMoa040583

Schwartz GG, Olsson AG, Ezekowitz MD, Ganz P, Oliver MF, Waters D, Zeiher A, Chaitman BR, Leslie S, Stern T; Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) Study Investigators. Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: the MIRACL study: a randomized controlled trial. JAMA. 2001;285(13):1711-1718. https://dx.doi.org/10.1001/jama.285.13.1711

Turner RM, Yin P, Hanson A, FitzGerald R, Morris AP, Stables RH, Jorgensen AL, Pirmohamed M. Investigating the prevalence, predictors, and prognosis of suboptimal statin use early after a non-ST elevation acute coronary syndrome. J Clin Lipidol. 2017;11(1):204-214. https://dx.doi.org/10.1016/j.jacl.2016.12.007

Kassab YW, Hassan Y, Aziz NA, Akram H, Ismail O. Use of evidence-based therapy for the secondary prevention of acute coronary syndromes in Malaysian practice. J Eval Clin Pract. 2013;19(4):658-663. https://dx.doi.org/10.1111/j.1365-2753.2012.01894.x

Pfeffer MA, Greaves SC, Arnold JM, Glynn RJ, LaMotte FS, Lee RT, Menapace FJ Jr, Rapaport E, Ridker PM, Rouleau JL, Solomon SD, Hennekens CH. Early versus delayed angiotensin-converting enzyme inhibition therapy in acute myocardial infarction. The healing and early afterload reducing therapy trial. Circulation. 1997;95(12):2643-2651.

Al Hilfi TK, Lafta R, Burnham G. Health services in Iraq. Lancet. 2013;381(9870):939-948. https://dx.doi.org/10.1016/S0140-6736(13)60320-7

Peterson GM, Thompson A, Pulver LK, Robertson MB, Brieger D, Wai A, Tett SE; DMACS Project Group. Management of acute coronary syndromes at hospital discharge: do targeted educational interventions improve practice quality?. J Healthc Qual. 2012;34(1):26-34. https://dx.doi.org/10.1111/j.1945-1474.2011.00137.x

Wilkins B, Hullikunte S, Simmonds M, Sasse A, Larsen PD, Harding SA. Improving the prescribing gap for guideline recommended medications post myocardial infarction. Heart Lung Circ. 2019;28(2):257-262. https://dx.doi.org/10.1016/j.hlc.2017.10.025

Hassan Y, Kassab Y, Abd Aziz N, Akram H, Ismail O. The impact of pharmacist-initiated interventions in improving acute coronary syndrome secondary prevention pharmacotherapy prescribing upon discharge. J Clin Pharm Ther. 2013;38(2):97-100. https://dx.doi.org/10.1111/jcpt.12027

Lowrie R, Mair FS, Greenlaw N, Forsyth P, Jhund PS, McConnachie A, Rae B, McMurray JJ; Heart Failure Optimal Outcomes from Pharmacy Study (HOOPS) Investigators. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction. Eur Heart J. 2012;33(3):314-324. https://dx.doi.org/10.1093/eurheartj/ehr433

Al-Jumaili AA, Hussain SA, Sorofman B. Pharmacy in Iraq: history, current status, and future directions. Am J Health Syst Pharm. 2013;70(4):368-372. https://dx.doi.org/10.2146/ajhp120415

Milfred-LaForest SK, Chow SL, DiDomenico RJ, Dracup K, Ensor CR, Gattis-Stough W, Heywood JT, Lindenfeld J, Page RL 2nd, Patterson JH, Vardeny O, Massie BM. Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. Pharmacotherapy. 2013;33(5):529-548. https://dx.doi.org/10.1002/phar.1295

Forsyth P, Warren A, Thomson C, Bateman J, Greenwood E, Williams H, Khatib R, Hadland R, McGlynn S, Khan N, Duggan C, Beezer J; United Kingdom Clinical Pharmacy Association Heart Failure Group and the Royal Pharmaceutical Society.A competency framework for clinical pharmacists and heart failure. Int J Pharm Pract. 2018 [Epub ahead of print]. https://dx.doi.org/10.1111/ijpp.12465

How to Cite
Nassr OA, Forsyth P, Johnson CF. Evaluation of discharge prescriptions for secondary prevention in patients with acute coronary syndromes in Iraq. Pharm Pract (Granada) [Internet]. 2019Mar.11 [cited 2019Aug.22];17(1):1372. Available from: https://pharmacypractice.org/journal/index.php/pp/article/view/1372
Original Research

Most read articles by the same author(s)