Evaluation of a pharmacist medicines optimisation clinic for high risk patients following STEMI

ST-elevation myocardial infarction (STEMI) is the most serious type of heart attack in which there is a complete blockage of the coronary artery, which can, in turn, lead to extensive damage to a large area of the heart. National guidelines state that following STEMI, patients should be initiated, and subsequently optimised on cardio-protective therapies. Local data demonstrated that although these medicines are started during the hospital admission, optimisation of dosages post discharge is uncommon. In 2013, we successfully introduced a pathway focusing on referral of high risk patients (those with left ventricular systolic dysfunction) to a pharmacist prescriber medicines optimisation clinic for up-titration.

Data was collated on the prescription of angiotensin converting enzyme (ACE) inhibitors, beta-blockers and eplerenone and the doses achieved for all STEMI patients referred to the pharmacist clinic for medicines optimisation in 2014–2015.

The overarching aim of this research project was to explore whether pharmacist-led clinic care could help to achieve the goal of optimisation of cardio-protective therapies for STEMI patients after their hospital discharge, as outlined in national guidelines.

Sixty one patients were referred to the clinic. At clinic discharge (n=59) all but one patient was prescribed an ACEI inhibitor or ARB (one contra-indicated: angio-oedema) and three patients were not prescribed a beta-blocker (bradycardia).

For ACEI /ARB, the target dose was attained in 14 patients (24 per cent) with 24 patients (41 per cent) reaching at least 50 per cent of the maximum dose. For beta-blockers, the target dose was attained in one case (two per cent) with only eight patients (13.5 per cent) reaching at least 50 per cent of the maximum dose.

Two-thirds of patients with an ejection fraction of less than 40 per cent were also prescribed eplerenone. Further analysis of these patients is not available.

The reasons that target doses were not achieved are shown in the diagram to the right. Clinical reasons relating to blood pressure, heart rate (beta-blockers) and renal function were dose limiting factors as well as logistical reasons for patients attending a hospital-based service

A pharmacist prescriber is well placed to offer a post discharge medicines optimisation in this high risk patient group. Titration of hospital discharge doses towards target levels is possible but clinical and logistical reasons often mean that target doses cannot be attained. Further evaluation of the appropriateness of eplerenone prescribing is required.

In addition, further research will explore the options regarding pharmacist-led medicines optimisation for all patients post discharge following STEMI and the preferred model of care.