Protected: Qi01 – Myocardial Infarction

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Operationalisation

Denominator

All patients aged 18–79 years who survived a myocardial infarction (ICD-10 I21, I22) requiring hospital care during the year.

Numerator

All defined in the denominator who were dispensed the following at least once within 6 months of the end of the hospital-level care episode:

  • ACEI or ARB (ATC C09A-D, C10BX04/06/07/10-21)
  • ADPs (clopidogrel, prasugrel, or ticagrelor ATC B01AC04/22/24)
  • lipid-lowering medications (statins ATC C10AA or C10BA except C10BA10, or C10BX, or combination products including a statin component A10BH5*; and/or PCSK9-inhibitors alirocumab C10AX14, evolocumab C10AX13, inclisiran C10AX16)
  • Beta-blockers (C07, C09BX02/04-07, C09DX05)

Exclusions (Numerator, denominator)

Patients aged below 18 or over 79 years at the end of the year of hospital discharge.
Patients who die or emigrate within 6 months (180 days) of the discharge.

Notes

If a patient has had multiple qualifying events during the year, the first one is included.
Dual antiplatelet therapy (DAPT) includes aspirin; however, because of over-the-counter sales its use is unlikely to be reliably captured from the registers.

Sources of Data

  • Population register
  • Secondary care patient registers
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Clinical guidelines

 2023 European Society of Cardiology Guidelines for the management of acute coronary syndromes (ACS) (8):

  • ACEIs have been demonstrated to improve outcomes in post-MI patients with additional conditions, such as heart failure and, diabetes, chronic kidney disease, and/or hypertension. ACEIs are recommended for acute coronary syndromes patients with health failure symptoms, LVEF ≤40%, diabetes, hypertension, and/or chronic renal disease. Contraindications include allergy, intolerance, angioedema, hyperkalaemia, hypotension, renal artery stenosis, worsening renal function.
  • Dual antiplatelet therapy (DAPT) including aspirin, and a potent P2Y12 receptor inhibitor (prasugrel or ticagrelor) is recommended as the default DAPT strategy for the first 12 months after acute coronary syndrome. Clopidogrel is recommended for 12 months if prasugrel and ticagrelor are not available, cannot be tolerated, or are contraindicated, and may be considered in older ACS patients (≥70–80 years).
  • High-dose statin therapy is recommended regardless of initial LDL-C values. If LDL-C goal is not achieved despite maximally tolerated statin therapy in 4–6 weeks, addition of ezetimibe is recommended. If LDL-C goal is still not achieved after 4–6 weeks, addition of a PCSK9 inhibitor is recommended.

2022 Finnish Current Care guidelines for acute coronary syndrome (ACS) (9):

  • An ACE-I (or ARB or valsartan and sacubitril) should be initiated to all patients with coronary artery disease who have hypertension, diabetes, chronic renal disease, or LVEF ≤40%, and no contraindications.
  • Aspirin and ADPs are recommended for 12 months after acute coronary syndrome.
  • Maximal statin treatment is recommended for all patients with acute coronary syndrome regardless of LDL-levels.

Similar or related indicators in Nordic or European quality assessment

 The European Society of Cardiology (ESC) Acute Cardiovascular Care Association (ACCA) QIs for acute MI care (10,11)

  • Prescription of low-dose aspirin (unless high bleeding risk or oral anticoagulation); P2Y12 inhibitors; ACEi) or ARB in patients with clinical evidence of heart failure or moderate/severe LV systolic dysfunction; beta-blockers (unless contraindicated) in patients with clinical evidence of heart failure or LVSD; and statins

Swedish quality registry SWEDEHEART (12) & Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror)

  • % of patients with MI, < 80 years, receiving P2Y12 receptor inhibitors at discharge. Patients with in-hospital bleeding or treatment with OAC or CABG are excluded.
  • % of patients with MI, < 80 years, in the target group (history of heart failure, rales on admission, left ventricular systolic dysfunction, diabetes mellitus or hypertension) receiving ACEi/ARB at discharge.

Norwegian Myocardial Infarction (Norsk hjerteinfarktregister) Register (13,14)

  • % of patients with MI, <85 years, prescribed antithrombotic medication at discharge.
  • % of patients with MI, <85 years, prescribed lipid-lowering medication at discharge.
  • % of patients with MI, <85 years, indication for beta blocker, prescribed beta blocker at discharge.

Set quality targets

The Norwegian quality register Norsk hjerteinfarktregister targets (14):

  • ≥90% of patients with type 1 myocardial infarction aged <85 years prescribed antithrombotic medication at discharge
  • ≥90% of patients with type 1 myocardial infarction aged <85 years prescribed lipid-lowering medication at discharge
  • ≥85% of patients with type 1 myocardial infarction aged <85 years prescribed beta blocker at discharge (if indicated)

The Swedish national quality register SWEDEHEART targets:

  • 85–90% of patients with MI, < 80 years, in the target group (history of heart failure, rales on admission, left ventricular systolic dysfunction, diabetes mellitus or hypertension) receiving ACEi/ARB at discharge (15)
  • 85–90% of patients with MI, <80 years, receiving P2Y12 receptor inhibitors at discharge (patients with in-hospital bleeding or treatment with oral anticoagulants or CABG are excluded) (16).

The Swedish National Board of Health and Welfare target (2014)

≥ 90% of patients with MI dispensed statins 12–18 months after discharge (17).

Similar or related indicators in international scientific literature

  • Secondary MI of a patients with history of MI and no use of aspirin and/or β-blocker (18,19)
  • People who attend primary care who have had a cardiac event and who have been prescribed a statin as a share of all people who attend primary care and who have had a cardiac event (20)
  • Aspirin, beta blocker, ACE-I or ARB, statin after MI and prescription filled within 30 days/90 days/one year after discharge (21)
  • Aspirin after angina, MI or coronary artery disease (22)
  • Antiplatelets for patients with coronary heart disease with preceding MI, dual antiplatelets for patients with ACS (23)
  • Beta blockers in coronary heart disease (CHD) and history of ACS, or stable angina without ACS (23)
  • Statin use after previous vascular event (23)
  • Dosing of statins simvastatin ≥40 mg/d (or equivalent) in patients with previous vascular event (23)
  • ACEIs or ARBs in patients with coronary heart disease and history of ACS (23)
  • Type 2 diabetes patients with a history of ischemic heart disease or MI prescribed beta blocker (24)
  • % of patients with MI who are not treated with ACEI, low doses of ASA and statins without justification (25)
  • Antiplatelets within 1 year of coronary artery stent insertion (Caughey et al. 2014, Australia (26))
  • Hospitalisation due to acute coronary syndrome for a patient with history of MI (in 2 years prior to admission) and no use of aspirin, β-blocker, ACEI or ARB and statin (in 3 months prior to admission) (26)
  • Beta blocker after MI (27)
  • Statin use after MI/IHD (28)
  • Secondary prevention of acute STEMI or NSTEMI: Start beta-blocker treatment, statins, ACEI or ARB, and dual antiplatelet therapy for up to 12 months, followed by long-term antiplatelet monotherapy (first-line treatment = low-dose aspirin) (Desnoyer et al. 2017, International (29))
  • Aspirin, statins after MI (30)
  • % of patients discharged after a MI who were prescribed and dispensed ACE-I or ARB, aspirin or an alternative anti-platelet therapy, and statin in the next year, and of those, the proportion who are using all for at least 80% of a one-year period (31)
  • Dual antiplatelet therapy after MI and stent insertion (32)
  • MI, with history of ACS/MI and no use of anti-platelet(s), beta-blocker (reduced left-ventricular systolic function only), or statins in the 3 months prior to hospitalisation. (32)
  • % of patients with a history of ACS who are not prescribed an antiplatelet agent (or anticoagulant), statin and ACEI or ARB (33)
  • Inappropriate: Percentage of patients with a documented history of coronary, cerebral or peripheral vascular disease, who are not prescribed a statin (unless the patient’s status is end-of-life or age is >85 years)((33)
  • Scoping review on indicators for ACS (aspirin, high-intensity statins, beta-blockers, ACEi/ARBs prescribed at hospital discharge) (34)

References

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  14. SKDE – Kvalitetsregistre [Internet]. [cited 2024 Apr 25]. Available from: https://www.skde.no/kvalitetsregistre/hjerteinfarkt/sykehus/?selected_row=hjerteinfarkt_ut_antitromb
  15. RAAS-hämmande läkemedelsbehandling vid hjärtinfarkt [Internet]. [cited 2024 Apr 25]. Available from: https://vardenisiffror.se/indikator/b6049b7a-6673-442c-9df7-6c3c702094f7?datefrom=2022-10-01&dateto=2024-03-31&gender&periodtype=quarter&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=malniva-kvalitetsregister&showtarget=false&units=07&units=06&units=13&units=01&units=05&units=20&units=19&units=09&units=22&units=10&units=14&units=21&units=18&units=04&units=17&units=03&units=08&units=23&units=25&units=12&units=24&units=se
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