Quality Control to Improve LDL-cholesterol Management in Patients with Acute Coronary Syndromes Based on the ACS EuroPath IV Project

Overview

Journal Eur Heart J Acute Cardiovasc Care

Publisher Oxford University Press

Specialty Cardiology & Vascular Diseases

Date 2023 Oct 13

PMID 37832522

Authors

Francois Schiele

Alberico L Catapano

Raffaele De Caterina

Ulrich Laufs

J Wouter Jukema

Azfar Zaman

Alessandro Sionis

Affiliations

Soon will be listed here.

Abstract

Aims: We performed quality control of lipid-lowering therapy (LLT) in patients with acute coronary syndrome (ACS), with a view to proposing corrective actions.

Methods And Results: Using a Define Measure Analysis Improve Control (DMAIC) approach applied to data from the ACS EuroPath IV survey, we measured attainment of two quality indicators (QIs) related to lipid-lowering treatment: (i) prescription of high-intensity statins (or equipotent treatment) before discharge, and (ii) proportion with LDL-cholesterol <55 mg/dL (1.4 mmol/L) during follow-up. A total of 530 European cardiologists responded and provided data for up to 5 patients from their centre, for acute and follow-up phases. Corrective measures are proposed to increase the rate of attainment of both QIs. Attainment of the first QI was measured in 929 acute-phase patients, 99% had LLT prescribed at discharge and 75% of patients fulfilled the first QI. Attainment of the second QI was assessed in 1721 patients with follow-up. The second QI was reached in 31% of patients. The DMAIC approach yielded 10 potential changes in prescription, 3 for the first and 7 for the second QI. The overall strategy is 'Fire to Target', i.e. early intensification of the LLT using statins, ezetimibe, bempedoic acid, and proprotein convertase subtilisin/kexin type-9 inhibitors, and is presented as an algorithm for routine application.

Conclusion: Quality control for LLT, based on the ACS EuroPath IV survey, detected 10 potential changes in prescription that could enhance attainment of 2 QIs. Whether the Fire to Target strategy will be adopted and effective needs to be assessed in further steps of the EuroPath Quality programme.

References

Cannon C, Blazing M, Giugliano R, McCagg A, White J, Theroux P . Ezetimibe Added to Statin Therapy after Acute Coronary Syndromes. N Engl J Med. 2015; 372(25):2387-97. DOI: 10.1056/NEJMoa1410489. View

Bebb O, Hall M, Fox K, Dondo T, Timmis A, Bueno H . Performance of hospitals according to the ESC ACCA quality indicators and 30-day mortality for acute myocardial infarction: national cohort study using the United Kingdom Myocardial Ischaemia National Audit Project (MINAP) register. Eur Heart J. 2017; 38(13):974-982. PMC: 5724351. DOI: 10.1093/eurheartj/ehx008. View

Schiele F, Farnier M, Krempf M, Bruckert E, Ferrieres J . A consensus statement on lipid management after acute coronary syndrome. Eur Heart J Acute Cardiovasc Care. 2016; 7(6):532-543. DOI: 10.1177/2048872616679791. View

Zusman O, Bebb O, Hall M, Dondo T, Timmis A, Schiele F . International comparison of acute myocardial infarction care and outcomes using quality indicators. Heart. 2019; 105(11):820-825. DOI: 10.1136/heartjnl-2018-314197. View

Moriarty P, Parhofer K, Babirak S, Cornier M, Duell P, Hohenstein B . Alirocumab in patients with heterozygous familial hypercholesterolaemia undergoing lipoprotein apheresis: the ODYSSEY ESCAPE trial. Eur Heart J. 2016; 37(48):3588-3595. PMC: 5233802. DOI: 10.1093/eurheartj/ehw388. View

Drexel H, Coats A, Spoletini I, Bilato C, Mollace V, Filardi P . An expert opinion paper on statin adherence and implementation of new lipid-lowering medications by the ESC Working Group on Cardiovascular Pharmacotherapy: Barriers to be overcome. Eur Heart J Cardiovasc Pharmacother. 2019; 6(2):115-121. DOI: 10.1093/ehjcvp/pvz079. View

Rathi R, Vakharia A, Shadab M . Lean six sigma in the healthcare sector: A systematic literature review. Mater Today Proc. 2022; 50:773-781. PMC: 8820448. DOI: 10.1016/j.matpr.2021.05.534. View

Ray K, Reeskamp L, Laufs U, Banach M, Mach F, Tokgozoglu L . Combination lipid-lowering therapy as first-line strategy in very high-risk patients. Eur Heart J. 2021; 43(8):830-833. DOI: 10.1093/eurheartj/ehab718. View

Schiele F, Gale C, Simon T, Fox K, Bueno H, Lettino M . The 2020 ESC-ACVC quality indicators for the management of acute myocardial infarction applied to the FAST-MI registries. Eur Heart J Acute Cardiovasc Care. 2021; 10(2):207-215. DOI: 10.1093/ehjacc/zuab010. View

10.

Gencer B, Mach F, Murphy S, De Ferrari G, Huber K, Lewis B . Efficacy of Evolocumab on Cardiovascular Outcomes in Patients With Recent Myocardial Infarction: A Prespecified Secondary Analysis From the FOURIER Trial. JAMA Cardiol. 2020; 5(8):952-957. PMC: 7240652. DOI: 10.1001/jamacardio.2020.0882. View

11.

Sionis A, Catapano A, De Ferrari G, Dudek D, Jukema J, Landmesser U . Improving lipid management in patients with acute coronary syndrome: The ACS Lipid EuroPath tool. Atheroscler Suppl. 2021; 42:e65-e71. DOI: 10.1016/j.atherosclerosissup.2021.01.011. View

12.

Nissen S, Lincoff A, Brennan D, Ray K, Mason D, Kastelein J . Bempedoic Acid and Cardiovascular Outcomes in Statin-Intolerant Patients. N Engl J Med. 2023; 388(15):1353-1364. DOI: 10.1056/NEJMoa2215024. View

13.

Aktaa S, Yadegarfar M, Wu J, Rashid M, de Belder M, Deanfield J . Quality of acute myocardial infarction care in England and Wales during the COVID-19 pandemic: linked nationwide cohort study. BMJ Qual Saf. 2021; 31(2):116-122. DOI: 10.1136/bmjqs-2021-013040. View

14.

Joy T, Monjed A, Zou G, Hegele R, McDonald C, Mahon J . N-of-1 (single-patient) trials for statin-related myalgia. Ann Intern Med. 2014; 160(5):301-10. DOI: 10.7326/M13-1921. View

15.

Nissen S, Stroes E, Dent-Acosta R, Rosenson R, Lehman S, Sattar N . Efficacy and Tolerability of Evolocumab vs Ezetimibe in Patients With Muscle-Related Statin Intolerance: The GAUSS-3 Randomized Clinical Trial. JAMA. 2016; 315(15):1580-90. DOI: 10.1001/jama.2016.3608. View

16.

Ray K, Molemans B, Schoonen W, Giovas P, Bray S, Kiru G . EU-Wide Cross-Sectional Observational Study of Lipid-Modifying Therapy Use in Secondary and Primary Care: the DA VINCI study. Eur J Prev Cardiol. 2021; 28(11):1279-1289. DOI: 10.1093/eurjpc/zwaa047. View

17.

Taylor M, McNicholas C, Nicolay C, Darzi A, Bell D, Reed J . Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2013; 23(4):290-8. PMC: 3963536. DOI: 10.1136/bmjqs-2013-001862. View

18.

Goldberg A, Leiter L, Stroes E, Baum S, Hanselman J, Bloedon L . Effect of Bempedoic Acid vs Placebo Added to Maximally Tolerated Statins on Low-Density Lipoprotein Cholesterol in Patients at High Risk for Cardiovascular Disease: The CLEAR Wisdom Randomized Clinical Trial. JAMA. 2019; 322(18):1780-1788. PMC: 6865290. DOI: 10.1001/jama.2019.16585. View

19.

Leonardi S, Montalto C, Carrara G, Casella G, Grosseto D, Galazzi M . Clinical governance of patients with acute coronary syndromes. Eur Heart J Acute Cardiovasc Care. 2022; 11(11):797-805. PMC: 9709629. DOI: 10.1093/ehjacc/zuac106. View

20.

Kim B, Hong S, Lee Y, Hong S, Yun K, Hong B . Long-term efficacy and safety of moderate-intensity statin with ezetimibe combination therapy versus high-intensity statin monotherapy in patients with atherosclerotic cardiovascular disease (RACING): a randomised, open-label, non-inferiority trial. Lancet. 2022; 400(10349):380-390. DOI: 10.1016/S0140-6736(22)00916-3. View