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Utilization trends of drugs in patients admitted with ischemic heart disease in a tertiary care teaching hospital

Background: Coronary artery disease (CAD) takes the highest toll of lives across the world as well as India. Prompt diagnosis and effective treatment is lifesaving. Drug utilization studies scrutinize the appropriateness of treatment and provide favourable feedbacks to strengthen clinical practices. Several other studies have reported underuse of four evidence-based medicines namely aspirin, β-blockers, angiotensin-converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB), and statins in patients with CAD. Polypharmacy, injection overuse is some of the shortcomings. The objectives of this study was to describe treatment practices in terms of different disease spectrum and drug utilization (group-wise and individually) for inpatients with CAD using core prescription indicators by WHO. Methods: A cross-sectional study of 4-month duration was undertaken for patients with CAD admitted to cardiology indoor of a tertiary care hospital. A total no of 143 prescriptions was screened and analyzed. Results: Males (67.13%) were more in number than females (32.87%). Age group from (57-66) topped in frequency (61.05%) ahead of (67 to 76) group (38.46%). Average no of drugs per patient were 8.056±1.97 and 5.86±0.14 for cardiovascular drugs. Prescription in generics (45.49%), antibiotics (0.61%), fixed-dose combinations (FDCs) (0.52%) and injectables (28.47%) were noted. The most common categories of CAD were ST-segment elevated myocardial infarction (69.23%) followed by chronic stable angina (17.48%). Antiplatelets (100%), hypolipidemics (99.3%), antianginals (60.14%), β-blockers (37.06%) and ACE-I/ARBs (27.97%) were utilized. Drugs from the national list of essential medicines were 66.49%. Conclusions: Among four evidence-based drugs, use of β-blockers and ACE-I/ARBs were inappropriately low. Polypharmacy and overuse of Injectable drugs are noted.


INTRODUCTION
Cardiovascular disease takes the highest toll on life across the world, approximately 1 in 3 deaths are documented. India is not far behind. The burden of cardiovascular disease is increasing over the years. 85% of all cardiovascular deaths are attributed to heart attack and stroke. 1 Ischemic heart disease (IHD) is the clinical spectrum of events resulting from the occluded coronary artery. High mortality and morbidity are part and parcel of IHD. Treatment involves many issues like prompt diagnosis, availability of life-saving medicines, early transfer, proper infrastructure, and above all treatment cost and patient affordability. Drug utilization study aims to find the appropriateness of treatment, identify shortcomings if any. WHO has devised core drug prescribing indicators meant to describe prescription practices in a representative sample of health facilities. 2 Periodic evaluations of drug use in each hospital setting provide favourable feedback for treating physicians to plan, modify and strengthen clinical practices to deliver a rational and cost-effective therapy.
Literature study yielded that evidence-based secondary preventive therapies especially 4 drugs/drug groups (aspirin, β blockers, ACE inhibitors or ARBs and statins) were under prescribed in tertiary care hospitals. 3,4 Polypharmacy, overuse of injections, low prescription from essential drug list are some of the shortcomings described by various studies.

Aims and objective
The aims and objectives of the study was to describe treatment practices in terms of different disease spectrum and drug utilization (group-wise and individually) for inpatients with ischemic heart disease using core prescription indicators by WHO. We went through all treatment records of inpatients of cardiology indoor within the study period diagnosed with ischemic heart disease or coronary artery disease (CAD) i.e., acute myocardial infarction (STEMI/NSTEMI) or unstable angina or chronic stable angina. 143 prescriptions in total were finally analysed after applying inclusion and exclusion criteria.

Inclusion criteria
Inclusion criteria were patients diagnosed as IHD (STEMI/unstable angina/ NSTEMI/chronic stable angina) and requiring drug treatment. Age >18 years of both genders. Patients admitted for at least 24 hours.

Exclusion criteria
Exclusion criteria were patients of IHD admitted for some investigations. IHD admitted for other medical problems like diarrhoea, dyselectrolytemia, etc.
Vulnerable groups and complicated post-MI cases with cardiogenic shock, severe heart failure, arrhythmia, embolic stroke, pericarditis, multi-infarct, mechanical trauma like papillary muscle rupture etc, are excluded.

Data collection
Total 143 patients' prescriptions were studied and included in the final analysis. The demographic data (age, sex), diagnosis, and presence of any other comorbid conditions were recorded from inpatient admission papers. Diagnoses were grouped in percentages according to different spectrums of IHD (STEMI, unstable angina or chronic stable angina or ACS with comorbidities). Data related to drugs prescribed were recorded as per WHO core prescription indicators i.e., average number of drugs per encounter, percentage of drugs prescribed in generics, percentage of encounter with injectables prescribed, percentage of encounters with antibiotics encountered, percentage of drugs from EDL (essential drug list). Percentage distribution of different classes of drugs (antiplatelets, antianginals, hypolipidemics, anticoagulants, antihypertensive, miscellaneous) have been studied and analysed. Individual drug distribution has been also studied.

Statistical analysis
Data were entered in MS excel 2019 and analysed. Descriptive statistics expressed in terms of actual numbers, and percentage and standard deviation. Data were compared with other prominent studies.

RESULTS
Total 143 patients' prescriptions were screened and analysed. From the demographic profile, it was observed that prevalence in males (67.13%, n=96) was more than in females (32.87%, n=47). The sex distribution is depicted in (Figure 1).   (Figure 3).  The categorization of patients of CAD based on the presence of concomitant diseases is depicted in (Figure 4 and Table 1). Of 143 patients, 71 (49.65%) patients had pure coronary artery disease without any comorbidity. Of the different cardiovascular drug utilization of antiplatelets/hypolipidemics is more than 90%. Whereas prescription of beta blockers (37.06%), ACE inhibitors (ACE-I) and ARBs (27.97%) is low. Antianginal use was documented by nearly 60%. Figure 5, graphically depicts the individual percentage of cardiovascular drugs which is also shown in (Table 3).   Hypertension (24.48%) and type 2 diabetes mellitus (9.79%) and both HTN and DM (16.08%) were the frequently associated co-morbid conditions in our study which was comparable to Saranya et al. 8 The average number of drugs per prescription was 8.06±1.97 (5.86±0.14) for cardiovascular drugs which clearly indicates polypharmacy but still was lower as compared to other studies (9.09±2.17) by Saranya et al, 16.21 (5.58) by Aswani et al, 9.16 (5.08±2.5) by Kerkar. 8,5,11 The WHO standard or ideal value for the average number of drugs per prescription is 1.6-1.8. 12 Cardiovascular diseases many times require urgent and aggressive treatment resulting in polypharmacy. Also, geriatric age group and its associated comorbidities increase the average drug usage per prescription which may be justified. The limitation is that the study was undertaken for only 4 months and not close to the WHO prescribed sample size.
Hence it may not have represented the total population. Secondly this data cannot be generalised for other set ups. Facility wise comparison with large multicentric study would have been better. Pharmacoeconomic parameters also could be incorporated with this study.

CONCLUSION
The over-all prescription patterns encountered in our study is optimal. However, polypharmacy, less adherence to EDL, less generic prescriptions are major shortcomings we found. Though antiplatelets, statins were maximally used (nearly 100%), underuse of beta blockers and angiotensin-converting enzyme inhibitor (ACEI) /angiotensin receptor blockers (ARBs) is still there in tertiary care setting. We also cannot ignore the gross deviations from standard guidelines -high use of ranolazine while 80% patients were in acute ischemic group, negligible use of antiplatelets other than aspirin and clopidogrel, less than 50% use of ACEI/ARBs in diabetic population. Finally, we conclude that further drug utilization studies with different groups of IHD with larger samples will ensure more rational and safer therapy to the patient. Treatment based on an appropriate hospital protocol for the emergency management of CAD can prevent polypharmacy, unwanted drug-drug interactions.