A new study using data from the Kerala ACS Registry, the largest, contemporary ACS registry in India to date, highlights a number of opportunities to improve the quality of acute coronary syndrome (ACS) management by focusing on reducing symptom-to-door time, door-to-needle time, and inappropriate use of thrombolysis and increasing use of recommended drugs.

The study, published on Sept. 7 in the European Heart Journal, looked at 25,748 ACS admissions from 2007 to 2009 in 125 hospitals throughout Kerala and evaluated data based on presentation, management, and in-hospital mortality and major adverse cardiovascular events (MACE). Results showed that in-hospital mortality and MACE rates were highest for ST-elevation myocardial infarction (STEMI) (8.2 to 10.3 percent). After adjustment, the STEMI diagnosis (vs. unstable angina) [odds ratio (OR), 95 percent confidence interval equals 4.06, 2.36 to 7.00], symptom-to-door time less than six hours [OR equals 2.29, 1.73 to 3.02], and inappropriate use of thrombolysis [OR equals 1.33, 0.92 to 1.91] were associated with higher risk of in-hospital mortality, and door-to-needle time greater than 30 minutes [OR equals 0.44, 0.27 to 0.72] was associated with lower mortality.

According to the study authors, the results underscore the importance of minimizing the time between symptom onset and presentation when coming from emergency care and going to the hospital. The data also indicate that combining antiplatelet, beta-blocker, and statin drugs should be a higher priority in comparison with the relatively high in-hospital and discharge nitrate use. In addition, authors also suggest that fixed dose combination, or polypill, therapy may be a strategy to help improve adherence and lower out-of-pocket costs for medication, while using a routine checklist when evaluating and managing ACS patients also has the potential to increase quality.

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