Clinical Studies
Successful implementation of guidelines for encouraging the use of beta blockers in patients after acute myocardial infarction

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Abstract

PURPOSE: To assess whether implementation of guidelines increases the prescription of drugs, particularly β blockers, recommended for secondary prevention after acute myocardial infarction.

SUBJECTS AND METHODS: Prescription patterns among 355 patients discharged from a public teaching hospital after recovery from myocardial infarction were prospectively monitored in a before-after trial. The implementation strategies included educational interventions (large group meetings), placement of guidelines in patients’ records, and bimonthly general reminders sent to physicians.

RESULTS: Beta blockers were prescribed in 93 (38%) of 243 survivors of acute myocardial infarction before guideline implementation (12-month control period), as compared with 71 (63%) of 112 patients (P <0.001) after their implementation (6-month period). During the entire study period, the prescription of β blockers at a neighboring public teaching hospital, used as a comparison, was unchanged. After adjusting for potential confounders, implementation of the guidelines remained significantly associated with prescription of β blockers at discharge [odds ratio (OR) = 10; 95% confidence interval (CI), 3.2 to 33; P <0.001]. Other independent predictors of prescription of β blockers were previous coronary artery bypass grafting (OR = 8.7; 95% CI, 2.5 to 31; P = 0.001), hypertension (OR = 2.5; 95% CI, 1.4 to 4.5; P = 0.003), age per 10-year increase (OR = 0.82; 95% CI, 0.67 to 0.99; P = 0.04), secular trend in prescription patterns expressed in months (OR = 0.9; 95% CI, 0.8 to 1.0; P = 0.02), a left ventricular ejection fraction ≤40% (OR = 0.2; 95% CI, 0.1 to 0.4; P <0.001), the presence of atrioventricular block (OR = 0.1; 95% CI, 0.02 to 0.7; P = 0.02), and concomitant prescription of digoxin (OR = 0.2; 95% CI, 0.05 to 0.8; P = 0.02) or calcium antagonists (OR = 0.06; 95% CI, 0.01 to 0.3; P = 0.001).

CONCLUSION: When appropriately developed and implemented by local experts, literature-based guidelines may be effective in modifying use of recommended drugs for secondary prevention of coronary artery disease, such as prescription of β blockers.

Section snippets

Setting and patients

This study was conducted in the general internal medicine wards of the Hôpital Cantonal, the main teaching hospital of the University of Geneva School of Medicine. This 1,200-bed urban public hospital is the major primary care hospital for the area. Although coronary care unit and cardiology faculty members are responsible for the initial care of patients with myocardial infarction during the first 48 hours, final hospital discharge decisions are made primarily by internists, as patients are

Results

Characteristics of the patients who were treated for acute myocardial infarction during the control period and the guidelines implementation period are shown in Table 1. The mean age of the patients was 66 years, and the majority were men. One third of the patients were older than 75 years. The past medical histories, cardiovascular risk factors, coexisting diseases (eg, diabetes), comorbidity scores, and the characteristics of the acute myocardial infarction were similar in the two groups.

Discussion

Mortality after myocardial infarction can be reduced by the selective use of aspirin, β blockers, and angiotensin-converting enzyme (ACE) inhibitors 9, 10, 11, 12, 13, 14, 22. Use of β blockers, in particular, is one of the best substantiated and cost-effective preventive strategies (23). However, results of randomized controlled trials often have limited impact on medical practice in general and medication use in particular: even cardiologists used β blockers in only 48% of eligible subjects

Acknowledgements

We would like to thank Sandro Pampallona, ScD, of Med, Geneva, Switzerland, for statistical assistance.

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    Supported in part by Grant 32-039288 from the Swiss National Fund for Scientific Research (JMG), by a grant from the “Fonds pour la collaboration entre les cantons de Vaud et Genève,” and by a grant from the Hôpital Cantonal, Geneva, Switzerland.

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