Y. Hassan

The impact of pharmacist‐initiated interventions in improving acute coronary syndrome secondary prevention pharmacotherapy prescribing upon discharge

Pharmacists have the knowledge regarding optimal use of medications and the ability to influence physician prescribing. Successful interventions by a pharmacist to implement cardioprotective medications to a coronary artery disease patients regimen would not only improve the patients quality of care but may also increase his or her likelihood of survival. Therefore, the aim of this study was to (i) evaluate the effectiveness of pharmacist initiated interventions in increasing the prescription rates of acute coronary syndrome (ACS) secondary prevention pharmacotherapy at discharge, and to (ii) evaluate the acceptance rate of these interventions by prescribers.

An analysis of clinical pharmacist interventions in an intensive care unit.

In a 6‐month study period, 170 pharmacist interventions in an intensive care unit (ICU) were analysed. Of the interventions, 68.8% were solicited and 31.2% were initiated by the pharmacists. The majority of the interventions were initiated by specialists (69.4%) followed by the medical officers (15.9%) and nurses (9.4%). Most of the interventions occurred during the grand rounds (75.9%), followed by ward visits (12.9%) and communication through the satellite pharmacy (10.5%). The most frequent type of intervention made was for indication or therapeutic efficacy followed by general product information, drug regimen, laboratory assessment, disease state, pharmaceutical availability and adverse drug reaction or side effect. It was also found that 83.7% of pharmacists suggestions were accepted, 6.4% were accepted with changes, and 9.9% were not accepted. The majority of the interventions were made by direct verbal communications followed by telephone and written communications. In conclusion the study indicates that pharmacist therapeutic recommendations form an important integral element of patient care in an ICU.

Use of evidence‐based therapy for the secondary prevention of acute coronary syndromes in Malaysian practice

RATIONALEnDespite the availability of various prevention guidelines on acute coronary syndrome (ACS), secondary prevention practice utilizing aspirin, beta-blockers, angiotensin converting enzyme inhibitors and statins still can be sub-optimal.nnnAIMS AND OBJECTIVESnTo review and document the utilization of pharmacotherapy for the secondary prevention of ACS in patients discharged from a Malaysian hospital.nnnMETHODSnA retrospective cross-sectional study was conducted at a tertiary hospital in Penang, Malaysia. Patients with a primary diagnosis of ACS were identified from medical records over a 4-month period. A range of clinical data was extracted from medical records, including medical history, clinical presentation and pharmacotherapy both on admission and at discharge. This audit focused on the use of four guideline-recommended therapies: aspirin ± clopidogrel, beta-blockers, statins and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blockers (ARBs).nnnRESULTSnData pertaining to a total of 380 ACS patients was extracted and reviewed, the mean age of the study population was 57.49 years and 73.9% of population was males. Patients with unstable angina accounted for 56.6% of the admissions whereas 23.4% and 20% of the patients were admitted for ST-elevation myocardial infarction and non-ST-segment elevation infarct respectively. 95.7% of the patients received antiplatelets comprising of at least aspirin, and 82% received aspirin plus clopidogrel. Furthermore, 80.3% of the patients received a beta-blocker at discharge, 95% a statin and 69.7% received either an ACEI or ARB. Compared with patients who presented with myocardial infarction (with or without ST-segment elevation), those presenting with unstable angina were less likely to receive the combination of aspirin plus clopidogrel or an ACEI/ARB at discharge. Patients over 65 years of age were also less likely to receive a beta-blocker at discharge, compared with younger patients.nnnCONCLUSIONSnThere is a good adherence to evidence-based guidelines for the secondary prevention of ACS in this local setting. However, there is some potential underutilization in the older population and patients presenting with unstable angina.

How to help patients to control their blood pressure? Blood pressure control and its predictor

Introduction: Good blood pressure (BP) control is one of the aims of hypertension disease management. Consistently achieving the targeted BP could reduce patient′s risk of developing the complication of hypertension. Materials and Methods: This study is a prospective cohort study aimed to investigate the blood pressure reading among in patients in a public tertiary hospital in northern Malaysia and to determine predictor of good BP control among patients. Patients were followed from their admission day until discharge. Data were collected by the researcher from the medical records. Information collected were BP reading on admission, day 1 and discharge. Other information includes demographic data, social factors, medication name and number, co-morbidities, target organ damage, cardiovascular risk factors. Descriptive analysis was done to determine the characteristic of patients and logistic regression was done to identify factors associated with BP control. Results: A total of 400 patients were followed up from admission till discharge. BP was controlled in 24% on admission and in 54% of patients on discharge. Multivariate analysis on admission revealed that the predictors of BP control were the use of diuretics and statin. Factors identified to be associated with poor BP control were diabetes mellitus, cerebrovascular disease and retinopathy. Multivariate analysis on discharge showed that the predictors of good BP control were diuretics and beta-blockers and the predictors of poor BP control were diabetes, chronic kidney disease, diabetic nephropathy, cerebrovascular disease and number of comorbidity. Conclusion: These results demonstrated that hypertension was poorly controlled among in-patients and that BP control was better on discharge than on admission. Patients with diabetes mellitus, renal disease and cerebrovascular disease were more likely to have poor hypertension control.

Antiplatelet therapy in diabetic ischemic stroke patients: associated factors and outcomes

BACKGROUNDnPatients with diabetes mellitus (DM) are more prone to develop atherosclerotic complications including stroke. Moreover, as a primary and secondary prevention of stroke, antiplatelet therapy is recommended by clinical guidelines for patients with DM.nnnAIMSnThis study aimed to determine the prevalence of antiplatelet therapy use prior to current stroke in diabetic ischemic stroke patients, to examine the factors associated with the use of this important therapy and to assess the impact of the previous use of antiplatelet therapy on ischemic stroke outcomes.nnnMETHODSnAn observational study of diabetic acute ischemic stroke patients attending a Malaysian hospital during a 1-year period was carried out. Demographic information, risk factors, previous antiplatelet use and variables used to assess stroke outcomes were collected from medical records.nnnRESULTSnOverall, 295 diabetic stroke patients were analyzed. The prevalence of previous antiplatelet use among diabetic patients was 38.3%. The independent variables associated with the previous use of antiplatelet medication were previous stroke attack (p < 0.001) and ischemic heart disease (p < 0.001). Better outcomes as measured by a minor Glasgow Coma Scale at admission (p = 0.032), and a higher Modified Barthel index at discharge (p = 0.027) were observed among patients on previous antiplatelet therapy.nnnCONCLUSIONnOur data suggest that antiplatelet therapy is under prescribed among such diabetic stroke patients, particularly in primary prevention. Effective methods to increase antiplatelet use and to enhance the adherence of clinical practice guidelines should be considered at the national and community level.

Impact of the Additive Effect of Angiotensin-Converting Enzyme Inhibitors and ⁄or Statins with Antiplatelet Medication on Mortality After Acute Ischaemic Stroke

There has been recent interest in combining antiplatelets, angiotensin-converting enzyme inhibitors (ACEIs) and statins in primary and secondary ischaemic stroke prevention. This observational study was performed to evaluate the impact of adding ACEIs and/or statins to antiplatelets on post-stroke in-hospital mortality. Ischaemic stroke patients attending a hospital in Malaysia over an 18-month period were evaluated. Patients were categorized according to their vital status at discharge. Data included demographic information, risk factors, clinical characteristics and previous medications with particular attention on antiplatelets, ACEIs and statins. In-hospital mortality was compared among patients who were not taking antiplatelets, ACEIs or statins before stroke onset versus those who were taking antiplatelets alone or in combination with either ACEIs, statins or both. Data analysis was performed using SPSS version 15. Overall, 637 patients met the study inclusion criteria. After controlling for the effects of confounders, adding ACEIs or statins to antiplatelets significantly decreased the incidence of death after stroke attack by 68% (p = 0.036) and 81% (p = 0.010), respectively, compared to patients on antiplatelets alone or none of these medications. Additionally, the addition of both ACEIs and statins to antiplatelet medication resulted in the highest reduction (by 94%) of the occurrence of death after stroke attack (p < 0.001). Our results suggest that adding ACEIs and/or statins to antiplatelets for patients at risk of developing stroke, either as a primary or as a secondary preventive regimen, was associated with a significant reduction in the incidence of mortality after ischaemic stroke than antiplatelets alone. These results might help reduce the rate of ischaemic stroke morbidity and mortality by enhancing the application of specific therapeutic and management strategies for patients at a high risk of acute stroke.

PCV4 EFFECT OF PRETREATMENT WITH ANGIOTENSIN-CONVERTING ENZYME INHIBITORS ON IN-HOSPITAL MORTALITY AFTER ACUTE ISCHEMIC STROKE

PCN39 TREATMENT PATTERNS AMONG PATIENTS WITH ADVANCED MELANOMA: A RETROSPECTIVE LONGITUDINAL STUDY O’Leary B, Colman S, Ruth A, Kotapati S, Cook G Covance Pty Ltd, North Ryde, NSW, Australia; Bristol-Myers Squibb Pharmaceuticals, Noble Park, VIC, Australia; Bristol-Myers Squibb Pharmaceuticals, Wallingford, CT, USA OBJECTIVES: A range of treatments have been used for late stage metastatic melanoma including chemotherapy, immunotherapy drugs (given alone or in combination), palliative surgery and radiation therapy. Nevertheless, current treatment practices in Australia for patients with advanced melanoma are poorly defi ned. As such, a retrospective longitudinal survey was conducted to gain an insight into the treatments currently used in this patient group. METHODS: Three Australian public hospitals provided patient level data. Inclusion criteria encompassed patients with a history of an unresectable stage III/IV melanoma (advanced melanoma) at initial diagnosis and had at least 6 months follow-up between January 1, 2005 and December 31, 2006. Information on demographics, disease characteristics, adverse events, survival and treatment history was obtained from medical records of all eligible patients. Descriptive statistics were performed for the four most frequently used fi rst-line treatments. Survival estimates were assessed using Kaplan Meier methods. Comparisons of survival by treatment choice were assessed using a log-rank test. RESULTS: In total, 51 patients were recruited with a mean age of 61.6 years and the majority Caucasian (96.1%). Twelve patients (23.5%) were stage III and 23 (45.1%) stage IV. Specifi c staging of remaining 16 (31.4%) advanced melanoma patients was unknown. The main fi rst-line treatments were dacarbazine (17.6%), fotemustine (15.7%), radiotherapy (23.5%), and surgery (23.5%). Patients treated with surgery were younger and mainly stage IV at diagnosis. Surgery was associated with longer survival (P = 0.0016); however, a causal relationship cannot be inferred. There was a tendency for fewer patients to receive surgery for second-line treatment with slightly more receiving radiotherapy. Chemotherapy was associated with nausea while hematological events were common in fotemustine patients. CONCLUSIONS: This study found that four main treatments are used for unresectable stage III/IV melanoma: dacarbazine, fotemustine, radiotherapy and surgery. The data suggests that surgery was associated with longer overall survival compared to the alternative therapies.