Preventing recurrent events in survivors of acute coronary syndromes in Australia: consensus recommendations using the Delphi process

Abstract

Objective: There remain substantial gaps in implementation of evidence-based care in patients with acute coronary syndromes (ACS) in Australia, which contribute to high recurrent event rates. Improved translation of evidence into effective action is a key health-care priority. We engaged cardiovascular experts from across Australia to develop straightforward, easily actionable recommendations on key medications to use following ACS.

Methods: An eight-person steering committee (SC) reviewed the published evidence and developed an initial set of statements to be developed into consensus recommendations using a modified Delphi technique. A panel of 21 expert cardiologists in the ACS field (including the SC) voted on their level of agreement with the statements using a 6 point Likert scale. Statements that did not reach consensus (≥80% agreement) were reviewed by the SC, modified as appropriate based on input from the panel and circulated for re-voting.

Results: Twenty-eight statements were developed by the SC across six classes of medication: low-density lipoprotein (LDL) cholesterol lowering agents, aspirin, dual antiplatelet therapy, renin–angiotensin–aldosterone system inhibitors, beta blockers and “other”. Twenty-six recommendations were endorsed by the voting panel; two statements did not reach consensus.

Conclusions: Despite the extensive evidence base and detailed guidelines outlining best practice post ACS, there remain considerable gaps in translating these into everyday care. We used an internationally recognized technique to develop practical consensus recommendations on medical treatment following ACS. These simple, up-to-date recommendations aim to improve evidence-based medication use and thereby reduce the risk of future cardiovascular events for Australian patients with ACS.

Keywords:

• Acute coronary syndrome
• aspirin
• angiotensin converting enzyme inhibitors
• angiotensin receptor antagonists
• beta adrenergic blockers
• antiplatelet agents
• LDL cholesterol

Transparency

Declaration of funding

Administrative and medical writing support was provided by Ms Donna Bartlett (Allori Pty Ltd, Australia) and Dr Anja Becher (Sydney, Australia) and was funded by AstraZeneca Australia. The sponsor had no role in the preparation of this article.

Author contributions: All authors were involved in the conception of the study, the design, analysis and interpretation of the data, the drafting of the paper and revising it critically for intellectual content. All authors approved the final version to be published and agree to be accountable for all aspects of the work.

Declaration of financial/other relationships

C.J.H. has disclosed that he has received research support, honoraria, or is a member of advisory boards: Amgen, AstraZeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Janssen, The Medicines Company, Medtronic and Merck Sharp and Dohme. J.A. has disclosed that he has received research support, honoraria, or is a member of advisory boards: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myer Squibb, Merck Sharp and Dohme, Pfizer and Sanofi Aventis. D.B. has disclosed that he has received research support, honoraria, or is a member of advisory boards: AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myer Squibb, Merck Sharp and Dohme, Pfizer and Sanofi Aventis. A.S. has disclosed that he has received honoraria, speaker fees, consultancy fees, is a member of advisory boards or has appeared on expert panels for: Abbott, Aspen, AstraZeneca, Bayer, Biotronik, Boehringer Ingelheim, Bristol Myer Squibb, CSL, Janssen Cilag, Menarini, Merck Sharp and Dohme, Novartis, Pfizer, Sanofi Aventis, Servier and Vifor. P.L.T. has disclosed that he has received honoraria for presentations and advisory boards from AstraZeneca, Boehringer Ingelheim and Pfizer, and research funding from AstraZeneca, Pfizer, Amgen and Bristol Myers Squibb. M.I.W. has disclosed that he has received honoraria, speaker fees, consultancy fees, is a member of advisory boards or has appeared on expert panels for: Abbott, Amgen, AstraZeneca, Bristol Myer Squibb, Eli Lilly, GlaxoSmithKline, Merck Sharp and Dohme, Pfizer and St Jude Medical. P.E.A. has disclosed that he has received research grants and honoraria for advisory boards from AstraZeneca, Elli Lilly, Sanofi Aventis, Boehringer Ingelheim, Amgen, CSL, Merck Sharp and Dohme, Bristol Myer Squibb, Bayer and Pfizer.

CMRO peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Full consensus group: John Amerena (Geelong Cardiology Research Centre, Barwon Health, Deakin University, VIC), Philip E. Aylward (Flinders University and Medical Centre, Adelaide, SA; and South Australian Health and Medical Research Institute, Adelaide, SA), Andrew Boyle (John Hunter Hospital, NSW), David Brieger (Cardiology Department, Concord Hospital and Sydney Medical School, The University of Sydney, Sydney, NSW), Clara K. Chow (The George Institute for Global Health, Sydney Medical School, Australia), David Cross (Heartcare Partners, QLD, and Royal Brisbane and Women’s Hospital, QLD), Deepak Haikerwal (Western Hospital, VIC), Christopher J. Hammett (Department of Cardiology, Royal Brisbane and Women's Hospital, QLD), Karam Kostner (Mater Hospital Brisbane and University of Queensland, QLD), Kumaril Mishra (Calvary Central Districts Hospital, SA), Allison Morton (St John of God Hospital, Bunbury, WA), Andrew T.L. Ong (Department of Cardiology, Westmead Hospital and Westmead Clinical School, University of Sydney, NSW), Rohan Poulter (Nambour General Hospital, QLD), Peter Psaltis (University of Adelaide and South Australian Health and Medical Research Institute, Adelaide, SA), Sharmalar Rajendran (University of Adelaide, SA), Jamie Rankin (Fiona Stanley Hospital, WA), Andrew Sindone (Cardiology Department, Concord Hospital and Sydney Medical School, The University of Sydney, Sydney, NSW), Peter L. Thompson (Heart Research Institute, Sir Charles Gairdner Hospital and Harry Perkins Institute of Medical Research, University of Western Australia, Perth), Philip Tideman (Country Health SA LHN and Southern Adelaide LHN, SA), Bill Van Gaal (Northern Hospital, VIC), Matthew I. Worthley (University of Adelaide, Royal Adelaide Hospital, Adelaide, SA; and South Australian Health and Medical Research Institute, Adelaide, SA).

Acknowledgements

We thank Professor Clara K. Chow (The George Institute for Global Health, Sydney Medical School, Australia) for her participation in this project as a member of the PERMIT Program Steering Committee. Administrative and medical writing support was provided by Ms Donna Bartlett (Allori Pty Ltd, Australia) and Dr Anja Becher (Sydney, Australia) and was funded by AstraZeneca Australia. The sponsor was given the opportunity to comment on the final version of the article.