Optimizing prevention and guideline-concordant care in Montenegro

BackgroundGuidelines recommend use of evidence-based medications in patients discharged after an acute coronary syndrome (ACS). Yet the current rates of adherence in many eastern European countries are unknown.ObjectiveTo determine whether 6 month outpatient follow-up after ACS is associated with recommended rates of medication adherence in Montenegro.MethodsA prospective analysis was conducted in 585 ACS patients confirmed to be alive after ACS at 6 month follow-up. The study was undertaken between 2012 and 2015, from 9 International Survey of Acute Coronary Syndrome in Transitional Countries (ISACS-TC) hospitals in the Montenegro. The primary outcome was guideline-concordant care, defined as 100% compliance with 5 medications: aspirin, clopidogrel, beta-blockers, and statins in ACS patients, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB] for the subset of patients with left ventricular systolic dysfunction, as assessed by an ejection fraction less than 40% at discharge. In addition to the composite end point, the achievement of each single treatment measure was analyzed. Multivariate predictors of long-term medication adherence were also identified.ResultsGuideline-concordant care (GCC) at discharge increased from 2012 to 2015 (adjusted OR for increase 1.51; CI 0.88–2.52). GCC over 6 months was adhered in 73% of patients. In patients who did not achieve GCC, adherence was persistently high with 92.3% for aspirin, 91.3% for statins and 72% for ACE-inhibitors or angiotensin-receptor blockers (ARBs). Adherence was lower for clopidogrel (57.7%) and beta-blockers (64.4%). After adjusting for demographic and clinical differences, in-hospital referral to PCI and ST segment elevation myocardial infarction (STEMI) were associated with greater medication adherence at 6 month follow-up.ConclusionsIn Montenegro, long-term adherence to evidence-based medication after ACS is high. Adherence to guideline-recommended therapies increased over time with participation to the ISACS-TC. The lower achievement of GCC in patients treated medically and in those with non-ST-segment elevation ACS needs particular attention.