Evaluation of management in acute coronary syndrome and extent of adherence to standard treatment guidelines


  • Aalesh Shah Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ellis-Bridge, Ahmedabad, Gujarat, India
  • Nehal R. Parikh Raptim Research Pvt Ltd, Navi Mumbai, Maharashtra, India; Department of Pharmacology, Smt. NHL Municipal Medical College, Ahmedabad, Gujarat, India
  • Devang Rana Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ellis-Bridge, Ahmedabad, Gujarat, India
  • Supriya Malhotra Department of Pharmacology, Smt. Nathiba Hargovandas Lakhmichand Municipal Medical College, Ellis-Bridge, Ahmedabad, Gujarat, India
  • Tejas Patel Department of Cardiology, SVP Hospital, Ellis-Bridge, Ahmedabad, Gujarat, India




Acute coronary syndrome, ACC/AHA guidelines, Guideline adherence index-5


Background: India has the highest burden of acute coronary syndrome (ACS) in the world. This research is to evaluate prescriptions pattern and extent of adherence to American College of Cardiology (ACC)\American Heart Association (AHA) guidelines in the management of ACS with patient outcome.

Methods: Case record form containing patient’s demographic, clinical profile, diagnosis, prescription drugs (with dose, duration and frequency) were noted. Pharmacotherapy was compared to ACC/AHA guidelines, to evaluate adherence, guideline adherence index (GAI-5) was used for 5 major drug groups for ACS. GAI was calculated as: number of patients using the prescribed medications/number of eligible patients multiplied by 100.

Results: A total of 172 patients diagnosed with ACS. 64 (37.20%) Patients with the highest preponderance to ACS belonged to 51-60 years age group with a 4.73:1 male to female ratio. ST-elevation myocardial infarction (STEMI) (44.77%) was the most common diagnosis and an average of 14.66±4.34 drugs were prescribed. Majority of the patients opted for percutaneous coronary intervention (PCI) with or without having received fibrinolytic therapy at onset. Adherence to the ACC/AHA guidelines being 93.75% and 118 prescriptions being 100% adherent to the guidelines. A positive correlation between adherence and number of drugs was statistically significant.

Conclusions: The success of evidence-based medicine (EBM) was well noted with a 0% in hospital mortality rate i.e. all of the 172 patients were discharged with therapeutic success. Despite the concept of EBM and its proven effectiveness, there is a paucity of availability of such guidelines in India, so this study, a first of its kind can serve as a starting point of generating national as well as local guidelines.


Fox K. Management of acute coronary syndromes. Variations in practice and outcome. Findings from the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2002;23(15):1177-89.

Hasdai D. A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin. The Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS). Eur Heart J. 2002;23(15):1190-201.

Medscape. Acute Coronary Syndrome. 2020. Available at: https://emedicine.medscape.com/article/ 1910735-overview. Accessed on 14 March 2022.

Xavier D, Pais P, Devereaux PJ, Xie C, Prabhakaran D, Reddy KS, et al. Treatment and outcomes of acute coronary syndromes in India (CREATE): a prospective analysis of registry data. Lancet. 2008;371(9622):1435-42.

Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K, et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. JAMA. 2007;297(3):286-94.

Sivadasanpillai H, Leeder SR, Huffman M, Jeemon P, Dorairaj P. A race against time: The Challenge of Cardiovascular Diseases in Developing Economies. Centre for Chronic Disease Control, New Delhi, India. 2015.

Prabhakaran D, Jeemon P, Roy A. Cardiovascular Diseases in India. Circulation. 2016;133(16):1605-20.

Eagle K, Lim M, Dabbous O. A validated prediction model for all forms of acute coronary syndrome: Estimating the risk of 6-Aug postdischarge death in an international registry. ACC Curr J Rev. 2004;13(8):9.

Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, et al. 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: A report of the American college of cardiology/American heart association task force on practice guidelines. Circulation. 2014;130(25):344-426.

Medscape. Acute Coronary Syndrome Guidelines. 2020. Available at: https://emedicine.medscape.com/ article/1910735-guidelines. Accessed on 14 March 2022.

Kumar M, Dahiya V, Mishra S, Sharma D, Mishra N, Lahkar M. Cardiovascular disease prevalence and drug utilization patterns at a tertiary care hospital in northeastern India. Int J Pharm Pharm Sci. 2016;116-9.

Mohanan PP, Mathew R, Harikrishnan S, Krishnan MN, Zachariah G, Joseph J, et al. Presentation, management, and outcomes of 25 748 acute coronary syndrome admissions in Kerala, India: results from the Kerala ACS Registry. Eur Heart J. 2013;34(2):121-9.

King-Shier K, Quan H, Kapral MK, Tsuyuki R, An L, Banerjee S, et al. Acute coronary syndromes presentations and care outcomes in white, South Asian and Chinese patients: a cohort study. BMJ Open. 2019;9(3):e022479.

El-Hajj M, Saad A, Al-Suwaidi J, Z. Al-Marridi W, H. Elkhalifa D, A. Mohamed A, et al. Utilization of evidence-based secondary prevention medications at the time of discharge in patients with acute coronary syndrome (ACS) in Qatar. Curr Vasc Pharmacol. 2016;14(4):394-403.

CURRENT-OASIS 7 Investigators, Mehta SR, Bassand J-P, Chrolavicius S, Diaz R, Eikelboom JW, et al. Dose comparisons of clopidogrel and aspirin in acute coronary syndromes. N Engl J Med. 2010;363(10):930-42.

Mehta SR, Yusuf S; Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) Study Investigators. The clopidogrel in unstable angina to prevent recurrent events trial investigators: effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. ACC Curr J Rev. 2002;11(1):13-4.

Ostadal P. Statins as first-line therapy for acute coronary syndrome? Exp Clin Cardiol. 2012;17(4):227-36.

Bainey KR, Armstrong PW, Fonarow GC, Cannon CP, Hernandez AF, Peterson ED, et al. Use of renin-angiotensin system blockers in acute coronary syndromes: findings from Get With the Guidelines-Coronary Artery Disease Program: Findings from Get With the Guidelines-Coronary Artery Disease Program. Circ Cardiovasc Qual Outcomes. 2014;7(2):227-35.

Miki T, Kita H, Miura T. ACE inhibitors use in patients with acute coronary syndrome. Nihon Rinsho. 1998;56(10):2601-6.

Chia PL, Foo D. Ivabradine is BEAUTIFUL in concurrent acute coronary syndrome and stroke. Int J Cardiol. 2013;163(2):21-2.

Gokhroo RK, Priti K, Ranwa BL, Anantharaj A, Kishor K, Pandey S, et al. Comparison of ivabradine and metoprolol in patients with acute inferior wall myocardial infarction: Expanding arena for ivabradine. J Am Coll Cardiol. 2016;67(13):535.

Wu M, Huang Z, Xie H, Zhou Z. Nicorandil in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis. PLoS One. 2013;8(10):e78231.

Ali MAS, Lobos CM, Abdelmegid MA-KF, El-Sayed AM. The frequency and nature of medication errors in hospitalized patients with acute coronary syndrome. Int J Clin Pharm. 2017;39(3):542-50.

Shimony A, Grandi SM, Pilote L, Joseph L, O’Loughlin J, Paradis G, et al. Utilization of evidence-based therapy for acute coronary syndrome in high-income and low/middle-income countries. Am J Cardiol. 2014;113(5):793-7.

Narwane DSP, Marawar AP, Shah J, Umar SA. Prescription pattern in patients of acute coronary syndrome in a rural tertiary care centre of Maharashtra. J Med Sci Clin Res. 2017;5(10).

Aronow HD, Topol EJ, Roe MT, Houghtaling PL, Wolski KE, Lincoff AM, et al. Effect of lipid-lowering therapy on early mortality after acute coronary syndromes: an observational study. Lancet. 2001;357(9262):1063-8.

Milicić D. ACE inhibitors and angiotensin II receptor antagonists in acute coronary syndrome. Acta Med Croatica. 2004;58(2):129-34.

de Matos Soeiro A, de Barros E Silva PGM, Roque EA de C, Bossa AS, Zullino CN, Simões SA, et al. Mortality reduction with use of oral beta-blockers in patients with acute coronary syndrome. Clinics (Sao Paulo). 2016;71(11):635-8.

O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction. Circulation. 2013;127(4):362-425.

Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. J Assoc Physicians India. 2011;59:19-25.

Rutherford JD, Braunwald E. Thrombolytic therapy in acute myocardial infarction. Chest. 1990;97(4):136-45.

Duarte GS, Nunes-Ferreira A, Rodrigues FB, Pinto FJ, Ferreira JJ, Costa J, et al. Morphine in acute coronary syndrome: systematic review and meta-analysis. BMJ Open. 2019;9(3):e025232.

Meine TJ, Roe MT, Chen AY, Patel MR, Washam JB, Ohman EM, et al. Association of intravenous morphine use and outcomes in acute coronary syndromes: results from the CRUSADE Quality Improvement Initiative. Am Heart J. 2005;149(6):1043-9.

McCarthy CP, Mullins KV, Sidhu SS, Schulman SP, McEvoy JW. The on- and off-target effects of morphine in acute coronary syndrome: A narrative review. Am Heart J. 2016;176:114-21.




How to Cite

Shah, A., Parikh, N. R., Rana, D., Malhotra, S., & Patel, T. (2022). Evaluation of management in acute coronary syndrome and extent of adherence to standard treatment guidelines. International Journal of Basic & Clinical Pharmacology, 11(5), 410–418. https://doi.org/10.18203/2319-2003.ijbcp20222136



Original Research Articles