Clinical pathway to improve treatment compliance, coronary revascularization rate, and patient outcome in non-ST elevation acute coronary syndrome (NSTE-ACS)

Abstract Description

Authors (including presenting author) :

Fang JX, Tam FCC

Affiliation :

Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong

Introduction :

Adherence to NSTE-ACS treatment guidelines is suboptimal especially in elderly patients. We examine the use of a checklist and a clinical pathway for better medical and interventional treatment.

Objectives :

to improve the efficiency of coronary workup and revascularization to improve the use of guideline-directed medical therapy to improve patient outcomes including all-cause mortality and major adverse cardiovascular event

Methodology :

294 out of 1510 consecutive patients, median age 79, were managed with a checklist at Queen Mary hospital, Hong Kong in 2014-18. Mean follow-up 463 days. Items on the checklist included medical therapy, risk assessment (Killip class/Grace score), and revascularization plan. Checklists were reviewed by cardiologists to plan further management. Data was collected retrospectively. Compliance to guideline-directed medical therapy, interventional strategy, major adverse cardiovascular event (MACE) and survival at 180 days, and length of hospital stay were compared. Multivariate Cox proportional hazard model adjusted for age, sex, diabetes, hyperlipidemia, hypertension, heart failure, history of stroke, ACS, and coronary revascularization, chronic kidney disease stage (Modification of diet in renal disease (MDRD)), Killip class, troponin elevation, malignancy, chronic lung disease, hemoglobin and bilirubin. Logistic regression, C-statistic, goodness-of-fit, followed by Propensity score matching gave 2 groups each of 294 risk-adjusted patients. Kaplan-Meier function and log-rank test were done.

Result & Outcome :

Use of a pathway decreased mortality and MACE in 180 days in the multivariate Cox model (hazard ratio 0.59, 95% CI 0.42-0.81, p=0.001 for death; 0.69, 95% CI 0.53-0.88, p=0.003 for MACE). The model based on logistic regression had a C-statistic of 0.83 for 180-day mortality. (Hosmer-Lemeshow goodness-of-fit p=0.18). After Propensity score matching, 42 patients (14.3%) in pathway versus 72 patients (24.5%) not in pathway died in 180 days (log-rank p=0.0099). MACE occurred in 61 patients (20.7%) in pathway versus 86 (29.3%) patients not in pathway (log-rank test p=0.0495). Inpatient revascularization approach was used in 51.0% of patients in the pathway group versus 21.4% not in pathway. Prescription of all major guideline-directed drugs improved. (98.0% vs 88.1% for statin, p< 0.001, 93.5% vs 75.9% for P2y12 inhibitor, p< 0.001). Median length of stay increased from 4 to 6 days. Conclusion: The pathway improved treatment and patient outcome but lengthened hospital stay.