Transition of care to prevent recurrence after acute coronary syndrome: the critical role of the primary care provider and pharmacist

ABSTRACT

Despite therapeutic advances, patients with acute coronary syndrome (ACS) are at an increased long-term risk of recurrent cardiovascular events. This risk continues to rise as the number of associated comorbidities, often observed in patients presenting with ACS, increases. Such a level of clinical complexity can lead to gaps in care and subsequently worse outcomes. Guidelines recommend providing an evidence-based post-discharge plan to prevent readmission and recurrent ACS, including cardiac rehabilitation, medication, patient/caregiver education, and ongoing follow-up. A patient-centric multidisciplinary approach is critical for the effective management of the transition of care from acute care in the hospital setting to the outpatient care setting in patients with ACS. Ongoing communication between in-hospital and outpatient healthcare providers ensures that the transition is smooth. Primary care providers and pharmacists have a pivotal role to play in the effective management of transitions of care in patients with ACS. Guideline recommendations regarding the post-discharge care of patients with ACS and the role of the primary care provider and the pharmacist in the management of transitions of care will be reviewed.

KEYWORDS:

• Acute coronary syndrome
• guidelines
• pharmacist
• primary care provider

1. Introduction

The underlying pathophysiology of acute coronary syndrome (ACS) involves coronary plaque disruption with associated atherothrombosis and subsequent myocardial ischemia and/or myocardial infarction (MI) [1,2]. ACS refers to a clinical spectrum of disease that includes ST-segment elevation MI (STEMI), non-ST-segment elevation MI (NSTEMI), and unstable angina (UA), which is related to the extent of intracoronary atherothrombosis.

ACS is associated with significant morbidity and mortality. The annual incidence of MI in the United States in 2018 was 805,000, of which 605,000 were new events and 200,000 (25%) were recurrent MI [3]. These data have been consistent over the years and reflect the significant risk of recurrent events. In 2016, approximately 14% (n = 111,777) of individuals who had an MI died as a result of it, and it is estimated that 335,000 Americans could have a recurrent MI or coronary heart disease event in 2019 [3]. The risk of a recurrent cardiovascular (CV) event or death is highest in the first year following an ACS event [4–5-6] and continues to increase for at least 5 years [6,7]. Even if there is no recurrence during the first-year post-MI, there is a 36% risk of MI, stroke, or death during the following 3-year period [7]. MI prevalence is almost twice as high for men than for women (4% vs 2.3%) in the United States, with the average age at initial MI slightly higher in women than in men (72.0 years vs 65.6 years) [3]. Patients with NSTEMI are generally older with a higher burden of disease and comorbidities, a level of clinical complexity necessitating effective transition of care management [8]. Reports indicate that two-thirds of MI are NSTEMI [9] with the risk of recurrent CV events being higher in patients with NSTEMI than in those with STEMI [8].

Considering the long-term risk of recurrent CV events following ACS and the exacerbation of that risk with the high number of comorbidities often observed in patients with ACS, such a level of clinical complexity can result in gaps in care, resulting in worse outcomes and significant healthcare utilization and cost burden.

Regardless of whether it is an initial or recurrent event [10,11], the greatest contributor to the cost burden is hospitalization [11,12], followed by office and outpatient visits [12]. Patients with recurrent ACS tend to have more comorbidities, a higher number of follow-up and emergency room visits, and more frequent use of laboratory services [11]. Overall, cardiovascular-related inpatient costs in the post-event period are 85%–260% higher than the period prior to the index event [13] and hospital readmission within 30 days is associated with an almost 50% increase in cumulative costs [14]. Substantial costs related to lost productivity have also been associated with ACS [15]. Although 6-month mortality rates over a 5-year period are decreased in patients with STEMI, mortality rates during the same time period show no improvement in patients with NSTEMI [16]. Multiple clinical and socioeconomic factors contribute to this residual risk. In addition, there are data suggesting that there is a considerable unmet need post-ACS for improvements in the transitioning of care from the hospital to the outpatient primary care setting, particularly among patients who have experienced an NSTEMI.

Current guidelines address the in-hospital and discharge/post-discharge medical management of ACS [1,17]. However, gaps in the care of patients with ACS remain, occurring at all stages from admission through to discharge from the hospital and into subsequent long-term follow-up care. These gaps in care can arise from both disease- and patient and healthcare provider-centered issues and can contribute to the significant residual risk seen in patients with ACS. For example, if patients are discharged lacking an understanding of their illness and/or their medication regimen, they may neglect to fill their discharge medications or inadvertently discontinue their medications [18]. A ‘Get With the Guidelines’ approach for post-hospital care should be in place to support patients with ACS during and after discharge to improve patient outcomes [1,17]. A process should be implemented including more effective discharge counseling, written discharge instructions, and post-discharge follow-up by the pharmacist and the primary care provider. In general, to achieve optimal post-discharge care, there must be a partnership between physicians (specialists and primary care providers), nurses, and pharmacists (hospital and community) [1,17].

2. Guideline recommendations for intermediate- and long-term care of the patient with a history of ACS

The overall goal of the acute and initial in-hospital management of the patient presenting with ACS is to reestablish and stabilize coronary blood flow, assess overall CV disease burden, and initiate appropriate treatment to reduce the likelihood of subsequent CV events. The 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guideline for the management of STEMI and the 2014 AHA/ACC guideline for the management of NSTEMI provide recommendations for the initial and subsequent long-term treatment of the patient with a history of ACS including both medical therapy and revascularization [1,17]. It is important to remember that all patients presenting with ACS should receive at least 12 months of dual antiplatelet therapy in addition to standard CV medications. While percutaneous coronary intervention (PCI) is the preferred method of reperfusion for patients with STEMI [17], because of their clinical characteristics at admission, a lower percentage of patients with NSTEMI undergo coronary angiography or subsequent PCI. Patients presenting with NSTEMI tend to undergo coronary artery bypass grafting (CABG) more often than patients presenting with STEMI, both during the initial hospitalization or following an ischemia-guided revascularization strategy [1,17].

All patients presenting with ACS should receive dual antiplatelet therapy using low-dose aspirin plus a P2Y₁₂ inhibitor, either a thienopyridine (clopidogrel or prasugrel) or a cyclopentyl triazolopyrimidine (ticagrelor) for at least 12 months post-ACS, regardless of whether treatment includes revascularization; continuation of dual antiplatelet therapy for longer than 12 months may be considered in patients undergoing stent implantation [1,17]. The guidelines recommend ticagrelor over clopidogrel in STEMI patients undergoing coronary stenting and in NSTEMI patients medically managed or undergoing coronary stent implantation (IIa LOE: B-R); prasugrel is recommended over clopidogrel in STEMI or NSTEMI patients undergoing a coronary stent implantation with a low risk of bleeding only (IIa LOE: B-R) [19].

The guidelines also recommend an evidence-based post-discharge care plan promoting effective secondary prevention to reduce recurrent CV events and hospital readmissions [1,17]. The care plan should include clear guidance on medication, physical activity/cardiac rehabilitation, and management of comorbidities/risk factors. It should provide patient/family education, attention to psychosocial and socioeconomic factors, and clear instruction on post-discharge follow-up with healthcare providers [1,17]. The effective implementation of a post-discharge care plan requires the involvement of several healthcare providers such as physicians (specialists/primary care providers), pharmacists (hospital/community), nurses, physical therapists, dietitians, psychologists, occupational therapists, and case managers [20]. Within this multidisciplinary team (MDT), the physician and the pharmacist play pivotal roles in the transition to primary care for the patient with ACS (Figure 1). Their attention to the transitions between care settings and follow-up after the transition ensures adherence to the care customized for the patient, resulting in improved patient outcomes [1,17]. Further details on the importance and the development of the MDT are discussed below.

Figure 1. Key aspects of the recommended post-discharge plan for patients with acute coronary syndrome where pharmacists and primary care providers can provide input to improve the transition of care [1,17]. ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker; CPR: cardiopulmonary resuscitation; EMS: emergency medical services; HF: heart failure; MI: myocardial infarction; MRA: mineralocorticoid receptor antagonist [17].

2.1. Post-discharge medications

Patients should receive guideline-directed therapy with appropriate and preferred medications at discharge [1]. In addition to dual antiplatelet therapy, these medications likely include long-term angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), diuretics, beta-blockers, calcium channel blockers, statins, and nitrates (Table 1) [1,17]. However, a multicenter US registry study has shown that adherence to guideline-directed medications decreases over time in post-MI patients, particularly in those with high mortality risk [21]. Similarly, a Danish database study observed that patients often did not receive target doses of beta-blocker therapy at 12 months after MI [22], suggesting that continued optimization of post-discharge medications is needed.

Table 1. Summary of post-discharge medications recommended for patients with ACS in addition to antiplatelet therapy [1,17]

Therapy	Guideline recommendations
Beta-blockers	STEMI/NSTEMI: Start oral beta-blocker therapy within first 24 hours in all patients without contraindication^a and continue after hospitalization
ACE inhibitors	STEMI: Start within first 24 hours in patients with anterior infarction, HF, or LVEF ≤40% (unless contraindicated)
	NSTEMI: Start and continue indefinitely in patients with LVEF ≤40% and in those with hypertension, diabetes, or stable CKD (unless contraindicated)
ARBs	STEMI/NSTEMI: Administer in patients who are intolerant to ACE inhibitors
MRAs	STEMI/NSTEMI: Start in patients with LVEF≤40% and either HF or diabetes who are already receiving ACE inhibitor and beta-blocker therapy (unless contraindicated^b)
Statins	STEMI/NSTEMI: Start high-intensity statin therapy in all patients (unless contraindicated)
Nitrates	STEMI: May be used in patients with hypertension and HF
	NSTEMI: Administer sublingual nitroglycerin every 5 minutes for up to 3 doses in patients with ongoing ischemic pain; IV nitroglycerin is indicated for the treatment of persistent ischemia, HF, or hypertension (unless contraindicated^c)
Calcium channel blockers	STEMI: May be useful in patients with AF who are intolerant to beta-blockers
	NSTEMI: Administer as initial therapy in patients with ongoing or recurring ischemia who are intolerant to beta-blockers (unless contraindicated^d)

^aContraindications include signs of HF, evidence of low output state, increased risk of cardiogenic shock, PR interval >0.24 seconds, second- or third-degree heart block, active asthma, and reactive airway disease.

^bContraindications include significant kidney impairment (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) or hyperkalemia (serum potassium >5.0 mEq/L).

^cContraindications include recent treatment with a phosphodiesterase inhibitor (sildenafil or vardenafil within the last 24 hours or tadalafil within 48 hours).

^dContraindications include clinically significant LV dysfunction, increased risk of cardiogenic shock, PR interval >0.24 seconds, and second- or third-degree atrioventricular block without a cardiac pacemaker.

ACE: angiotensin-converting enzyme; AF: atrial fibrillation; ARB: angiotensin receptor blocker; CKD: chronic kidney disease; HF: heart failure; IV: intravenous; LVEF: left ventricular ejection fraction; MI: myocardial infarction; MRA: mineralocorticoid receptor antagonist; NSTEMI: non-ST segment-elevated MI; STEMI: ST segment-elevated MI.

The patient’s understanding and ability to adhere to his or her prescribed medication should be reviewed by the hospital pharmacist and any potential medication adherence problems addressed prior to discharge [23]. A randomized trial found that post-discharge counseling by the patient’s primary care provider and community pharmacist may also improve outcomes, especially in those with a low level of health literacy [24]. In a prospective UK study, pharmacist-led clinics and cardiology MDT collaboration showed improved medication optimization in post-MI patients who attended these clinics, with significantly increased odds of ACE inhibitor/ARB and beta-blocker prescriptions and achievement of target doses of these medications compared with baseline [25].

3. Ensuring continuity of care for ACS patients

Because post-discharge care is multifaceted, an MDT is required to ensure comprehensive care for patients with ACS following hospital discharge [20]. The MDT generally includes a team leader, for example: a hospitalist, cardiologist, emergency department physician, or other clinical lead; a content expert, usually a cardiologist (particularly when one is not the team leader); a team facilitator for assisting with the organizational aspects of the team and the plan; and process owners or participating frontline healthcare providers [20]. Additionally, good communication among the members of the MDT is paramount to ensure accurate medication reconciliation, attention to transitions between care settings, and consistent documentation [1,17].

The ACS guidelines recommend that every patient and/or his or her caregiver(s) receive a post-discharge plan prior to hospital discharge [1,17] and that the plan be shared with the primary care provider responsible for post-discharge patient care [26]. Providing the post-discharge plan to the patient’s primary care provider is crucial to ensuring a smooth transition to primary care. On the day of discharge, the primary care provider should be informed of the discharge diagnosis, medical diagnostic results, including any pending test results, prescribed medications, follow-up arrangements, and suggested next steps [23,27]. Within a week of discharge, the primary care provider should have received a detailed discharge summary, including additional information on diagnoses, abnormal physical findings, test results, discharge medications, including the rationale for new or changed medications, details of the counseling provided to the patient and his or her family/caregivers, and remaining tasks that need to be completed (Figure 1) [23,27]. Follow-up by the primary care provider with the patient’s discharge team can address any errors or questions pertaining to discharge medications or test results [23]. The primary care provider may need to assist the patient with scheduling follow-up testing and appointments to monitor overall recovery. During their appointments, the primary care provider should continue to provide the patient with ongoing counseling about the disease and the treatment plan to ensure adherence. Regular primary care visits may assist with long-term patient adherence to lifestyle changes, as well as reducing anxiety and allowing for medication review [28]. A retrospective study of elderly patients with ACS showed that regular general practitioner consultation was associated with reduced risk of mortality and hospitalization [28]. Similarly, a systematic review of randomized studies found that primary care organizational interventions for secondary prevention of ACS, including patient and physician education, management of risk factors, and preplanned follow-up visits, were associated with a 20% reduction in the overall risk of mortality [29].

The pharmacist also plays a critical role in the transition of patients to primary care. Both pre- and post-discharge, hospital pharmacists can provide patient counseling or education, and can reconcile medications and detect medication discrepancies [27,30,31]. Recommendations for optimization of therapy can be provided by the pharmacist in both the inpatient and outpatient setting, and should include drug monitoring, initiation or discontinuation of medication, and titration of medication [30]. A multicenter retrospective study showed that hospitals that include an inpatient credentialed cardiology pharmacist in their MDT have improved medication-related process of care measures compared with hospitals without an inpatient cardiology pharmacist [32]. In the outpatient setting, community pharmacists are responsible for ensuring the appropriate use of medications and for compiling an accurate and complete record of a patient’s medications in cooperation with the patient’s primary care provider, specialist, and any other pharmacies the patient uses [31]. The prospective UK pilot study that showed improved medication optimization through the utilization of pharmacist-led clinics included both specialist cardiology pharmacists and community-based pharmacists [25], emphasizing the importance of the community pharmacist in post-discharge follow-up care. The involvement of a pharmacist can also help decrease the costs of the patient’s medication, which can help reduce medication discontinuation or abandonment rates [30]. As part of medication management, the pharmacist can counsel the patient about substitution with generic medications, specifically the differential outcomes between branded and generic therapies, and coordinate the distribution of drug coupons or copay cards and approval of Medicare tier exception [30]. Patient engagement in these discussions and in the final decision-making process is paramount to furthering adherence to their medications.

4. Cardiac rehabilitation

The 2018 ACC/AHA cardiac rehabilitation guidelines recommend referral of all eligible patients to a comprehensive outpatient cardiac rehabilitation program prior to hospital discharge or during the first outpatient visit to reduce risk of readmission and death after MI, as well as health-related quality of life and psychological well-being [33–35]. Key components of a cardiac rehabilitation program are education, lifestyle risk factor management (exercise, diet, and smoking cessation), psychosocial health, medical risk factor management, cardioprotective therapies, and long-term management [36]. The cardiac rehabilitation team generally includes a cardiologist, nurse specialist, physical therapist, dietitian, psychologist, exercise specialist, occupational therapist, and clerical administrator [36]. This team should actively engage and communicate effectively with the wider MDT, including the patient’s primary care provider and pharmacist.

Real-world studies have indicated that community-based cardiac rehabilitation, including a collaboration between the primary care provider and cardiologist, improves the odds of achieving all therapeutic goals (i.e. medications, lifestyle, and risk factor control recommendations) [37] and leads to improvements in left ventricular ejection fraction, exercise tolerance, and cardiovascular risk factors [38]. When compared with hospital-based cardiac rehabilitation in a randomized trial, shared-care rehabilitation involving healthcare centers and primary care providers demonstrated similar effects on medication adherence and cardiovascular risk factors [39], as well as similar total healthcare-associated costs [40].

Several studies have demonstrated the benefits of pharmacist involvement in cardiac rehabilitation. A retrospective study showed that MDT-based cardiac rehabilitation with clinical pharmacist involvement improved adherence to ACE inhibitors and beta-blocker therapy and decreased rates of readmission [41]. Furthermore, clinical pharmacist involvement in cardiac rehabilitation was associated with a reduction in drug-related problems in a randomized trial, as well as improvements in medication adherence, patient knowledge regarding secondary prevention of ACS, and health-related quality of life [42]. Similarly, in a prospective real-world study, hospital-based rehabilitation with clinical pharmacist involvement led to improvements in physical and mental health at 1-year post-discharge [43].

Barriers to cardiac rehabilitation include lack of referrals, low rates of adherence, financial hardships related to lack of insurance and the need to return to work, transportation problems, and lack of coordination between inpatient and outpatient physicians [34,44,45]. Primary care providers can work to overcome some of these barriers by referring patients to cardiac rehabilitation [1] and counseling patients and caregivers about resources available in the community for cardiac rehabilitation [34,35]. Adherence to cardiac rehabilitation may also be improved by linking primary care services and cardiac rehabilitation with nurse-led prevention clinics [34].

5. Importance of medication adherence

It is important that patients are discharged with an individualized, evidence-based medical regimen and that they understand the importance of adhering to the plan. Improved medication adherence reduces the risk of rehospitalization and adverse outcomes [46,47]; poor adherence to discharge medications in patients post-MI is a significant independent predictor of higher rates of heart disease–related readmission [48].

There are many healthcare provider- and patient-centric issues that contribute to nonadherence to a treatment plan. Potential barriers to medication adherence after discharge include an incomplete or inaccurate medication history at initial admission, changes to medications during admission, poorly communicated discharge instructions to the patient, a lack of understanding about medication refills, poor transfer of information to the primary care provider [49], adverse events [50], and financial hardship [51]. Many of these barriers can be eliminated by direct communication between the pharmacist and the patient’s primary care provider [52,53]. Patient characteristics that increase overall clinical complexity can also affect medication adherence post-ACS, including increased age, and the presence of any or all of the following: diabetes, peripheral artery disease, a diagnosis of atrial fibrillation or heart failure, liver or kidney disease, and psychosocial issues such as depression [50,51,54]. In our experience, medication adherence may also be affected by an inability of the pharmacy to fill the prescription, which can lead to the patient not receiving the required medications and thus to poor outcomes. There are critical steps that should be taken before the patient is discharged. The prescribing physician (hospital specialist and/or primary care provider) and pharmacist (hospital and/or community pharmacist) should make sure that (a) the order arrives at the pharmacy; (b) it is covered by the patient’s insurance; (c) any prior authorization is complete; and (d) the patient and family/caregivers receive discharge counseling to ensure understanding of the importance of the prescribed medications. A significant delay in obtaining required medications may lead to significant negative outcomes, including but not limited to re-admission or another event.

Open communication between patients and their healthcare providers, and active engagement of patients in their treatment plan positively impact post-discharge medication adherence. Development of a mutually respectful relationship between patient and healthcare providers (e.g. primary care provider, pharmacist, nurse, or social worker) has a positive impact on patients’ attitude about adherence [55]. Additionally, regular contact between patients and their community pharmacist helps to emphasize the importance of taking their medications [55]. Pharmacist involvement in patient education, medication reconciliation, delivery of discharge medications, and post-discharge follow-up has also been shown to significantly improve patient medication adherence and literacy 30 days post-discharge in a single-center prospective study of patients with STEMI [56]. Randomized trials have confirmed that interventions led by both hospital-based and community pharmacists, including accurate medication reconciliation, patient education regarding barriers to adherence, and collaborative care between pharmacists and primary care providers, improved medication adherence [53,57]. The benefits of a team approach to post-ACS care were also demonstrated in an Italian cohort study, which found that patients were more likely to adhere to evidence-based medications over 2 years after MI if they were under the care of general practitioners in group practice than if their general practitioner was in single-handed practice [58]. At discharge, the intervention should include written medication instructions, verification that the patient has understood these instructions, management of potential adherence issues, and a medication reconciliation to the primary care provider and community pharmacist [31]. Data suggest that patients receiving explanations from the hospital and community pharmacists and/or primary care provider on the reasons for each medication and the potential adverse effects of the medications are related to increased persistence with ACS-related medications [54].

Follow-up with the primary care provider is usually scheduled within 2 weeks of discharge or sooner if necessary [27]. Hospital pharmacists can also be involved in the management of post-discharge follow-up to assist in the effective transition of patients to primary care [27]. The hospital pharmacist can follow up with the community pharmacist to identify and rectify any prescription discrepancies and to communicate a reconciled medication list. Telephone follow-up by the pharmacist (hospital and/or community pharmacist) 2–4 days after discharge may reduce the risk of rehospitalization [31], as this provides an opportunity to answer any patient questions and address any new or worsening symptoms [27]. Any concerns regarding the patient’s medications can also be discussed, including an inability to fill prescriptions or problems with understanding the new regimen.

6. Education and follow-up

The ACCF/AHA 2013 STEMI guidelines recommend that patients receive educational interventions [17]. In addition to the medication plan and a referral to cardiac rehabilitation, the patient (and caregiver) should also receive education regarding follow-up care. Patient and caregiver education can emphasize information about (1) warning symptoms, (2) having a survival plan, and (3) knowing the risks associated with delaying treatment, which can ultimately improve the likelihood of surviving a recurrent acute MI [17,59]. Information and support on lifestyle changes, including smoking cessation, dietary modifications, and physical activity, should also be provided [1,17]. The healthcare providers participating in the patient’s care (e.g., inpatient physicians, primary care providers, hospital and community pharmacists, nurses, cardiac rehabilitation staff, and dieticians) play an integral role in providing these educational interventions.

7. Conclusions

Patients presenting with ACS or with a history of MI have a high long-term risk for recurrent CV events. While baseline patient characteristics and comorbidities related to the underlying pathophysiology of ACS certainly contribute to this long-term risk, there are a number of critically important patient- and healthcare provider-centered issues. Effective management of transition of care through a coordinated patient-centered approach can help to further reduce the risk of recurrent CV events and achieve optimal patient outcomes. The primary care provider and the pharmacist are in an ideal position to improve outcomes for patients with ACS through their roles in the effective management of transition of care.

Declaration of interest

JG has participated in speakers bureaus for Novo Nordisk and Sanofi, and provides consulting services for Becton Dickinson. FH reports no conflicts of interest.

Reviewer disclosure

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

Author contributions

JG and FH have contributed to the development and review of the manuscript and approved of the final version of the manuscript for submission.

Acknowledgments

Medical writing support was provided by Sheridan Henness, PhD, and Sarah Greig, PhD, inScience Communications, Springer Healthcare (Auckland, NZ), in accordance with Good Publication Practice (GPP-3), and funded by AstraZeneca. AstraZeneca provided content review of the manuscript for scientific accuracy.

Additional information

Funding

The development of this manuscript was supported by AstraZeneca.