DEPARTMENT OF PHARM
ACY
UNIVERSI
TY OF MA
LTA
Antiplatelet and Anticoagulation Treatment for Non-ST-Elevation
Acute Coronary Syndromes
Giorgia Mason*, Francesca Wirth**, Lilian M. Azzopardi**, Robert G. Xuereb***, Andrea Cignarella*
Department of Pharmacy
University of Malta
*Università degli Studi di Padova, Italy
**Department of Pharmacy, Faculty of Medicine and Surgery, University of Malta, Malta
***Cardiac Catheterisation Suite, Cardiology Department, Mater Dei Hospital, Malta
Email: giorgiamason5888@gmail.com
INTRODUCTION
AIM
The 2011 European Society of Cardiology (ESC)
guidelines on the management of acute coronary
syndromes
without
persistent
ST-elevation
(NSTE-ACS) define fundamental steps regarding
pharmacological management in the acute phase of
NSTE-ACS
during
hospitalisation,
including
1
antithrombotic treatment.
To assess compliance with the ESC guidelines for
antiplatelet and anticoagulation therapy in patients
diagnosed with NSTE-ACS at the time of coronary
angiogram at Mater Dei Hospital (MDH).
METHOD




University Research Ethics Committee approval was obtained.
A data collection form (DCF) to gather information about patient demographics, social and medical history,
laboratory investigations and prescribed medications was developed and psychometrically evaluated.
Inpatients diagnosed with NSTE-ACS were recruited by convenience sampling from the Cardiac Catheterisation
Suite, MDH, over a 5-month period.
The DCF was completed for each patient by reviewing patient treatment files, following discussions with
consultant cardiologists and nurses and by attending procedures performed.
RESULTS
RESULTS
Patient demographic information
Compliance to guidelines for antiplatelet treatment
+ proton pump inhibitors
A total of 165 patients were recruited. 73% of the
patients were male, 37% were between 66 and 75
years and 44% were current smokers. Common risk
factors for cardiovascular disease were hypertension
(BP >140/90 mm Hg) (27%), dyslipidaemia (LDL
cholesterol >2 mmol/L; triglycerides >2.26 mmol/L)
2
and obesity (BMI >30 kg/m ) (both 16%). Following
coronary angiogram, 41% of the patients underwent a
percutaneous coronary intervention, either ad hoc
(34%) or elective (7%).
Eighty patients were prescribed a proton pump
inhibitor (PPI) with dual antiplatelet therapy (DAPT).
Sixty-five of these patients were given PPIs against
guideline recommendations since they were given
omeprazole, which is preferably not recommended in
the guidelines to be used with clopidogrel. Four
patients
were
prescribed
alternative
PPIs
(2 pantoprazole, 2 rabeprazole), which are not
available on the Maltese GFL.
Compliance to guidelines for antiplatelet treatment
Compliance to guidelines for anticoagulant treatment
Prescription of aspirin 300mg loading dose (LD) and
75mg daily dose (DD) was according to guidelines in
the majority of patients (95% and 97% respectively).
Prescription of clopidogrel 300mg LD and 75mg DD
was also according to guidelines in the majority of
patients (88% and 97% respectively). In patients (4)
scheduled for an invasive strategy immediately
post-hospital admission, a 600mg LD of clopidogrel
was required and was given according to guideline
recommendations. Prasugrel was only prescribed in 2
patients since it is not available on the Maltese
Government Formulary List (GFL).
The majority of patients were prescribed heparin
anticoagulation treatment in combination with DAPT
according to guidelines (95%). With regards to
anticoagulation treatment, evaluation of ischaemic
and bleeding risk was undertaken according to
guidelines in 96% of the patients. Enoxaparin 1mg/kg
twice daily SC was prescribed according to guidelines
in 81% of the patients. Alternative antithrombotic
drugs recommended in the guidelines, such as
ticagrelor, glycoprotein IIb/IIIa receptor inhibitors,
fondaparinux and bivalirudin were never prescribed
since they are not yet available in Malta.
CONCLUSION
Prescription of antiplatelet and anticoagulation therapy for NSTE-ACS at MDH is predominantly in accordance with
ESC guidelines. Alternative antiplatelet drugs, anticoagulants and PPIs should be considered for inclusion in the
Maltese hospital formulary to improve NSTE-ACS management in line with European guidelines.
Reference
1. Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients
presenting without persistent ST-segment elevation. Eur Heart J 2011; 32: 2999–3054.