Post-Acute Coronary Syndrome Discharge and Long-term Follow-up: Recommendations for Thailand

Cardiovascular disease (CVD), and ischaemic heart disease (IHD) in particular, is the leading contributor to disease burden and mortality worldwide and in Thailand.^1,2 Mortality related to IHD has steadily risen in Thailand from 44.8 deaths per 100,000 population in 2000 to 73.8 deaths per 100,000 population in 2021.³ In 2019, Thailand’s public healthcare expenditure was US$19 billion, with the highest budget allocated to CVD prevention and treatment.⁴ Furthermore, patients with acute coronary syndrome (ACS), a sequelae of atherosclerotic CVD (ASCVD), comprising a group of conditions including unstable angina and MI with or without observed ST elevation (ST-elevation MI [STEMI]/non-STEMI), remain at very high risk of recurrent cardiovascular events or death, especially within the first year after an initial ACS event.^5,6 Although registry data from Thailand have shown a decrease in the in-hospital mortality rate among Thai patients with ACS over the years, the 1-year post-discharge mortality remains high (14–25%).^7–9 Given the significant public health and economic burden of IHD on the healthcare system in Thailand, it is crucial that the primary care of post-ACS patients is optimised beyond the acute hospitalisation phase to reduce the secondary risk of subsequent cardiovascular events.

Secondary prevention after an ACS event is central to reducing cardiovascular morbidity and readmission rates, restoring quality of life and maintaining or improving functional capacity.^1,10 Guidelines for the management of ACS that provide evidence-based strategies for the treatment of acute events, as well as the primary and secondary prevention of CVDs in clinical practice, are widely available.^11–16 Despite this, studies worldwide and in Thailand have shown a suboptimal prescription of guideline-recommended therapies upon discharge following an acute ACS event and poor adherence to these therapies, with inadequate control of risk factors.^17–20 Several factors could influence a patient’s post-ACS discharge journey, including inadequate knowledge and awareness among physicians and patients, a lack of communication between cardiologists and other healthcare practitioners directly involved in patient care and limitations in healthcare infrastructure, regulations and resources in local settings.^21,22 Therefore, an evidence-based and comprehensive post-ACS discharge care plan that includes clear guidance on medications, patient education regarding the importance of adherence to medications, counselling on lifestyle modification for the management of cardiovascular risk factors and a follow-up care plan is the cornerstone for reducing recurrent cardiovascular events and hospital readmissions, as well as societal cost of CVDs, in the long term. Such a discharge care plan should be tailored to local settings, taking into account healthcare systems and infrastructure, available resources and local practices.

The Thai ACS guidelines were developed in 2020 with the aim of ensuring that all patients with ACS have timely access to effective treatment while reducing mortality and morbidity from ACS.²³ Although the diagnosis and acute clinical management of ACS are addressed in the guidelines, there is limited guidance with respect to post-discharge and long-term management of post-ACS patients, highlighting a gap in long-term secondary prevention. In this paper, we aim to identify the current clinical practice for the post-discharge management of patients with ACS and provide recommendations to support healthcare providers in Thailand to optimise the management of post-ACS patients during and following discharge.

Methodology

The steering committee (the authors of this paper) comprised eight leading cardiologists from tertiary care hospitals in Thailand with acknowledged clinical experience in managing patients with ACS in their practice.

The first step was to undertake a comprehensive literature review to synthesise evidence based on publicly available research and clinical practice guidelines. Following this, we developed a survey questionnaire to assess current clinical practice in the post-discharge management of patients with ACS in Thailand. This survey was administered to 30 cardiologists and 30 interventional cardiologists from public hospitals (n=36) and academic/university centres (n=24) in Bangkok (n=38) and the rest of the country (n=22).

In addition, three virtual steering committee meetings were organised in November 2021, March 2022 and March 2024 to discuss the findings of the survey and the literature review, and to obtain insights into real-world practices. At these meetings, the essential elements of the post-ACS discharge plan, post-discharge follow-up and long-term management of patients were outlined and discussed. After the meetings, recommendations on identified elements were made via email correspondence and the recommendations were developed.

Our recommendations are based on available evidence as well as our combined clinical experience, and we have accounted for the healthcare practices, challenges and opportunities unique to Thailand. All recommendations were agreed on by all members of the steering committee.

Discharge and Follow-up Plan

After experiencing an ACS event, patients often lack a full understanding of what has occurred.¹⁵ Cognitive impairment, as a complication of ACS, can also make it difficult for patients to understand care instructions at discharge.¹⁵ Anxiety and depression following an ACS event are also common and increase the risk of non-adherence to medication plans and prescribed lifestyle changes and, consequently, major adverse cardiovascular events (MACE) and death.¹⁵ One in every three to five patients experiences repeat cardiovascular events following discharge.²⁴ Furthermore, persistence with the medication plan wanes over time; one study reported that nearly one-third of patients who experienced an MI were no longer persisting with their prescribed medications by 6 months.^18,25

Suboptimal management of discharge medications has been identified as one of the risk factors contributing to recurrent cardiovascular events.¹⁷ Indeed, a retrospective study of patients with ACS in a tertiary care centre in Thailand between 2013 and 2018 found that only 43% of patients were discharged with optimal medical therapy, which was defined as treatment with the five-drug regimen recommended by the European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association, consisting of antiplatelet therapy with aspirin and P2Y₁₂ inhibitors, statins, β-blockers and angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs).¹⁸ Furthermore, optimal medical therapy was reported to be associated with a reduction in all-cause mortality and MACE in patients with ACS.¹⁸ Hence, it is imperative to devise a well-established plan in conjunction with a multidisciplinary team comprising the cardiologist/interventional cardiologist, nurses, rehabilitation specialists, physiotherapists, pharmacists and dieticians, prior to the patient’s discharge. Discharge information should be communicated to the patients and their caregivers verbally, as well as in a written format, and their understanding of the same should be assessed. Regular and consistent patient follow-up after ACS can help prevent premature recurrent events, and hence, follow-up appointments should be scheduled for 12 months. A patient-centred approach, with a particular focus on those at risk of non-adherence, must be taken to assess and address the educational needs of each patient, and information about recognising the symptoms of ACS and the relevance and importance of secondary prevention strategies should be emphasised. Figure 1 outlines our recommended framework for a discharge protocol, including mandatory and optional activities for a comprehensive post-discharge plan, which should be tailored to individual patients.

In addition, estimation of 10-year CVD risk can help support discharge planning. The Secondary Manifestations of ARTerial Disease (SMART) risk score, specifically designed to assess the risk of recurrent cardiovascular events in patients with established CVD, can be used to tailor secondary prevention strategies.²⁶ The SMART risk score is based on easy-to-measure clinical patient characteristics, has multinational validity and high generalisability and so can be used in routine healthcare settings to guide decision-making for secondary prevention.²⁶

While planning discharge, clinicians need to be cognisant of common complications following an acute ACS event. For example, it has been shown that 15–20% of patients with acute MI can have heart failure (HF) as a complication and 12–15% develop HF following discharge.²⁷ Mortality is higher among MI patients with HF as a complication than among those without HF.²⁸ Therefore, patients with HF should be appropriately managed according to the guideline recommendations, including early (within 24 h) initiation of ACEI and early (within 7 days) use of aldosterone antagonists.^15,29 In addition, the identification of those who are at risk of HF is important so that appropriate therapy can be provided.

In our survey of practising cardiologists and interventional cardiologists in Thailand (n=60), we found that 60% of survey respondents followed a predischarge checklist before discharging post-ACS patients from their hospital; the reasons provided for following the checklist included ensuring patient safety, quality of life and better outcomes, preventing complications and readmissions, and minimising medical errors (Supplementary Figure 1). The respondents who did not use a predischarge checklist highlighted the inconvenience of using a checklist. To address this gap, we have provided easy-to-use pre- and post-discharge follow-up checklists for patients admitted with an acute ACS event (Supplementary Tables 1 and 2).

Medication Plan

Antiplatelet Management

Dual antiplatelet therapy (DAPT) consisting of aspirin (at a maintenance dose of 75–100 mg) and a P2Y₁₂ inhibitor is an integral part of the pharmacological treatment aiming to prevent atherothrombotic complications in patients with ACS and is recommended by guidelines for a minimum of 12 months after an ACS event, regardless of stent type, unless contraindicated.^30,31 Some exceptions include patients who need surgery urgently, patients who are indicated for anticoagulation and patients who have very high bleeding risk for other reasons.^30,31 Of note, there is variation in the duration of DAPT use across Asia and direct adoption of Western guidelines may not be appropriate in Asian populations.³² However, an expert consensus group in Thailand has also recommended DAPT duration in all ACS settings for at least 12 months based on available evidence.³³ This consensus further outlines how to choose P2Y₁₂ inhibitors in DAPT across several settings of ACS, including maintenance DAPT in ACS.³³ The addition of a P2Y₁₂ inhibitor at a maintenance dose to aspirin therapy is recommended in all patients with ACS for a duration of 12 months, except in the case of patients at high bleeding risk.¹⁵

Clopidogrel, ticagrelor and prasugrel are oral P2Y₁₂ receptor blockers available in Thailand, whereas cangrelor is an intravenous medication not available in Thailand. In addition, clopidogrel and ticagrelor are listed in the national drug list that can be reimbursed under certain conditions.³³ The Cardiac Intervention Association of Thailand and the Heart Association of Thailand have endorsed the benefit of prasugrel and ticagrelor over clopidogrel.³⁴ We recommend the use of any available P2Y₁₂ inhibitor as part of maintenance DAPT after ACS, but there are several caveats worth noting. Ticagrelor at a maintenance dose of 90 mg twice daily is recommended regardless of the treatment strategy (invasive or conservative).¹⁵ Prasugrel at a maintenance dose of 10 mg once daily for up to 12 months should be confined to patients receiving PCI.¹⁵ Prasugrel should be used with caution in patients aged ≥75 years or with a bodyweight <60 kg, and these patients should be offered a lower maintenance dose of 5 mg once daily.¹⁵ Prasugrel should not be used in patients with active bleeding or a history of stroke, transient ischemic attack or intracranial haemorrhage due to the risk of significant or fatal bleeding.^13,14 Ticagrelor or prasugrel in combination with an anticoagulant should not be routinely offered to patients who need an ongoing separate indication for anticoagulation.³⁵ Clopidogrel at a maintenance dose of 75 mg once daily is recommended when ticagrelor or prasugrel are not available, cannot be tolerated or are contraindicated, and may be considered in older patients (typically defined as those aged >70–80 years).¹⁵

Lipid Management

It has been demonstrated that lower LDL levels after ACS are associated with lower cardiovascular event rates, and hence, LDL is the primary target for lipid-lowering interventions.³⁶ A retrospective cohort study at a tertiary care hospital in Thailand that included 405 patients diagnosed with ACS and treated with statins demonstrated a 71% lower incidence of total recurrent cardiovascular events in patients who achieved LDL levels <1.81 mmol/l compared with those with an LDL ≥2.59 mmol/l (p=0.028).³⁷ The absolute cardiovascular benefit of LDL lowering depends on a patient’s cardiovascular risk and the absolute reduction in LDL.³⁸ Hence, patients who are at high risk of cardiovascular events would still benefit from a small absolute reduction in LDL.

However, in the real world, many patients fail to achieve the LDL target despite the use of lipid-lowering therapies. In a pan-Asian survey on lipid-lowering treatment for hypercholesterolemia, only 34.9% of very high-risk patients attained the target LDL level.³⁹ Alarmingly, in Thailand, only 16.7% of very high-risk patients with ACS achieved the target LDL of <1.81 mmol/l at the 4-month follow-up.⁴⁰ In a recent real-world study in Thailand, less than 25% of patients with STEMI who underwent primary PCI achieved the LDL target at the 3-month follow-up.⁴¹ In this context, more aggressive lipid-lowering efforts are warranted in patients with ASC in Thailand.

Timing and Treatment Goals

Lipid-lowering therapy should be initiated as early as possible before discharge for its prognostic benefit and better post-discharge adherence.¹⁵ Achieving a ≥50% reduction in LDL from baseline and lowering LDL to <1.42 mmol/l is required to reduce the risk of MACE.^13,15 For secondary prevention, the ESC guidelines recommend achieving a ≥50% reduction in LDL from baseline and lowering LDL to <1.42 mmol/l, and, if a second cardiovascular event is experienced within 2 years or while the LDL level was <1.81 mmol/l, a goal of LDL <1.03 mmol/l may be considered.¹⁵ A stepwise treatment-intensification approach may be used, taking into account anticipated benefits, side effects and patient preference (Figure 2).

Treatment Choice

Lipid-lowering drugs currently available include statins (inhibitors of 3-hydroxy-3-methylglutaryl-coenzyme A reductase), fibrates, bile acid sequestrants, selective cholesterol absorption inhibitors (e.g. ezetimibe) and PCSK9 inhibitors. Because LDL reductions in response to therapy exhibit interindividual variability, it is imperative to monitor the effects of treatment on LDL levels and to identify adverse events, ideally 4–6 weeks after treatment initiation or change (Supplementary Table 3).^12,15

A high-intensity statin, such as atorvastatin or rosuvastatin, should be initiated at the earliest opportunity and continued long term in all statin-naïve patients who have no contraindications, regardless of initial LDL levels (Figure 2).^12,15 Patients who are already receiving low- or moderate-intensity statin treatment prior to the acute ACS event should be prescribed up to the highest tolerated high-intensity dose unless contraindicated.¹⁵ A retrospective cohort study in Thai ACS patients who had undergone primary PCI to identify patterns of statins prescribing and the impact on lipid profiles reported a lower use of high-intensity statins compared with moderate-intensity statins, and a greater reduction in LDL levels in patients who received high-intensity statins versus those who did not at the 3-month follow-up (38.22% versus 22.36%; p<0.01).⁴²

The addition of ezetimibe and/or a PCSK9 inhibitor can benefit patients who are already on the highest-tolerated statin dose but are unable to achieve the treatment goal after 4–6 weeks of statin-only therapy, or patients who cannot tolerate statins (Figure 2).^15,23 As monotherapy, ezetimibe can reduce LDL by 15–22%; the addition of ezetimibe to statin produces an additive effect, providing an additional 21–27% reduction in LDL.^43,44 Considerations that may favour ezetimibe versus a PCSK9 inhibitor as the initial choice of non-statin add-on therapy include the patient requiring a <25% additional LDL reduction, recent (<3 months) ACS, cost considerations, patient preference and ease of use.⁴⁵ Conversely, a PCSK9 inhibitor may be preferred as the initial non-statin add-on therapy of choice in patients requiring a >25% additional LDL reduction in view of its demonstrated safety, efficacy and benefits for cardiovascular outcomes in the FOURIER and Odyssey Outcomes trials.⁴⁵ Inclisiran, a recently approved long-acting (twice-yearly regimen) small interfering RNA, may be used in place of a PCSK9 inhibitor in patients who are unable to tolerate or adhere to a PCSK9 inhibitor treatment regimen (Figure 2).⁴⁵

A retrospective study assessed LDL goal attainment (<1.81 mmol/l) during a follow-up period of 2 weeks–1 year in ACS patients treated with high- and low-potency statins in routine practice in Thailand and found that only 24% of patients reached their target LDL, with no difference in LDL goal attainment between the high- and low-potency statin groups (24.9% versus 23.4%, respectively).⁴⁶ The authors surmised that inadequate statin therapy could be a reason for the non-attainment of target LDL: 98% of patients in the cohort were on statin monotherapy.⁴⁶ Furthermore, of the 25% of patients with LDL >3.62 mmol/l at baseline who would benefit from combination therapy, including a statin to achieve their target LDL, only 1.8% were receiving combination therapy.⁴⁶ The gap could potentially be due to the prescribing physicians’ fear of adverse effects of increasing the intensity of statins or adding non-statins to the regimens and/or issues with access to and the availability of agents. Poor adherence to lipid-lowering therapy could also be a reason for failure to attain LDL goals. This calls for a concerted effort to improve the knowledge and awareness of physicians, as well as patients, regarding the importance of LDL goal attainment for the prevention of future cardiovascular events.

Blood Pressure Management

It is well established that elevated blood pressure (BP) is the major cause of ASCVD.¹³ Antihypertensive treatment in patients with a clinical history of CVD but without hypertension is associated with a reduction in absolute all-cause mortality of 13.7 per 1,000 persons treated.⁴⁷

Treatment Target

All post-ACS patients should have their BP reduced to <140/90 mmHg as a first step.¹² Subsequent BP targets should be tailored to age and specific comorbidities (Supplementary Table 4).^12,48

Treatment Choice

Optimal BP control is rarely achieved using single-drug therapy.¹² Hence, a polypill is recommended for more effective BP reduction and for better adherence.^12,15 There are five major classes of BP-lowering drug therapy that have shown benefit in reducing cardiovascular events: ACEIs, ARBs, β-blockers, calcium channel blockers (CCBs) and thiazide or thiazide-like diuretics.

Long-term ACEIs should be considered in all post-ACS patients independent of their LVEF, especially in those with HF, LVEF ≤40%, T2D, hypertension and/or chronic kidney disease, due to their ability to limit infarct size and ventricular remodelling.^13,15,35 Complete titration of ACEIs to the highest tolerated dose should preferably be done prior to discharge; if not feasible, titration should be completed within 4–6 weeks of discharge.³⁵ ARBs should be used as an alternative in patients who cannot tolerate ACEIs.¹³

A β-blocker should be initiated and continued long term in post-ACS patients who have an LVEF ≤40%, regardless of HF symptoms.^15,35 An observational study suggested that post-ACS patients with reduced LVEF who were prescribed β-blockers at discharge had lower 1-year MACE than those who were not discharged with β-blockers; a similar association was not observed in those with preserved LVEF.⁴⁹ Because evidence for the long-term use of β-blockers among those with preserved LVEF is inconclusive, the indication for use beyond 12 months should be reassessed in patients who were initiated on β-blockers for previous ACS without a history of/current reduced LVEF, angina, arrhythmias or uncontrolled hypertension.^13,35

Additional BP-lowering agents, such as thiazide diuretics, CCBs and mineralocorticoid receptor antagonists, can be considered when BP is not sufficiently controlled by ACEIs/ARBs and β-blockers.¹³ Although not associated with prognostic benefits, CCBs can be considered for residual angina and BP control.¹⁵ Non-dihydropyridine CCB (e.g. verapamil and diltiazem) should not be used in the presence of HF or impaired LVEF.⁵⁰ A mineralocorticoid receptor antagonist, such as eplerenone, is recommended for post-ACS patients with an LVEF ≤40% and HF or T2D because its use has been shown to be associated with reduced mortality and cardiovascular hospitalisations in patients with a recent MI and left ventricular dysfunction with symptoms of either HF or T2D.¹⁵

Blood Glucose Management: Type 2 Diabetes

Approximately 25–30% of patients admitted to hospitals with ACS also have diabetes, and their outcome is poorer with respect to cardiovascular morbidity and mortality compared with that of non-diabetic patients.⁵¹ Patients with ACS and T2D have been reported to experience prolonged hospitalisation, higher 30-day readmission rates and worse mortality rates than the general population.⁵² Poor acute and long-term risk factor management in post-ACS patients with T2D is associated with worse long-term prognosis.⁵³

A high prevalence of diabetes was seen in patients with STEMI in the Thai ACS registry, and these patients were at increased risk of adverse outcomes, including HF, arrhythmia, bleeding and death, compared with patients without diabetes.⁵⁴ A 2018 nationwide survey in Thailand showed a higher prevalence of IHD in people with diabetes than in the general population. The Thai National Health Examination Survey 2004–14 showed that 48% of people with diabetes had hypertension, 71% had elevated LDL levels and almost one-fifth had a BMI of ≥30 kg/m².^55,56 These conditions are known risk factors for MACE, and hence, there is a need for regular assessment and better control of risk factors in these patients.

Treatment Target

Regardless of T2D history, all patients presenting with acute ACS should have their glycaemic status evaluated during hospitalisation.¹⁵ Any diagnosis of T2D made during hospitalisation should be subsequently confirmed given that ACS may cause hyperglycaemia due to catecholamine-induced stress.¹⁵

Although a lower HbA_1c target has shown clear benefits in reducing microvascular complications, its benefit on macrovascular complications is less well established.^57,58 A U-shaped relationship between HbA1c and clinical outcomes has been suggested, where severe hypoglycaemia is a potent marker for high absolute risk of cardiovascular events and mortality.⁵⁹ Hence, the HbA_1c target should be individualised to avoid hypoglycaemia while taking into account comorbidities, life expectancy and the duration T2D.^59,60

Treatment Choice

The ESC recommends prescribing glucose-lowering medications with two parallel, mutually exclusive intentions: to improve cardiovascular outcomes and safety; and to control blood glucose.⁶⁰ Priority should be given to glucose-lowering medication with proven cardiovascular benefits, followed by medication with proven cardiovascular safety, over medication without proven cardiovascular benefits or safety.⁶⁰ Two classes of glucose-lowering medications, namely SGLT2i and GLP-1RA, have shown potent cardiovascular benefits that are independent of their glucose-lowering effects, especially in reducing MACE.⁶¹

SGLT2i are the preferred glucose-lowering therapy for T2D patients with established ASCVD, independent of both baseline/target HbA1c and concomitant glucose-lowering medications such as metformin.⁶⁰ A meta-analysis showed that SGLT2i reduces MACE by 11% among patients with established ASCVD and reduces risk of renal disease progression by 45% regardless of ASCVD.⁶² A real-world study in patients with T2D from the Asia-Pacific, Middle East and North America demonstrated that SGLT2i were associated with a lower risk of cardiovascular events, with consistent results in patients with or without established CVD.⁶³ In Thailand, Krittayaphong et al. reviewed available evidence and recommended SGLT2i for T2D patients with established ASCVD to reduce MACE, hospitalisation for HF and worsening of renal outcomes.⁵⁶ An SGLT2i is also recommended for T2D patients who have established HF either with or without reduced LVEF.⁶⁴ Dapagliflozin and empagliflozin have been shown to reduce the risk of HF worsening or cardiovascular death in patients with HF regardless of their LVEF status and the presence or absence of T2D.^64–67 SGLT2i with proven cardiovascular benefits are empagliflozin, canagliflozin and dapagliflozin.⁶⁰ However, caution is advised for their use in patients with type 1 diabetes or in patients with advanced chronic kidney disease (e.g. estimated glomerular filtration rate <30 ml/min/1.73 m²).¹³

Similar to SGLT2i, GLP-1RAs are also recommended in patients with T2D and established ASCVD to reduce cardiovascular events, independent of baseline/target HbA1c and concomitant glucose-lowering medications such as metformin.⁶⁰ A meta-analysis showed that the use of GLP-1RAs is associated with a 12% reduction in MACE.⁶⁸ In a trial-level meta-analysis evaluating GLP-1RA and SGLT2i in the prevention of major cardiovascular and renal outcomes in T2D, both agents reduced MACE to a similar degree in patients with established ASCVD, but SGLT2i demonstrated a more marked effect on preventing hospitalisation for HF and progression of kidney disease.⁶⁹ This difference in profile should be considered in the decision-making process in the management of patients with T2D. GLP-1RAs with proven cardiovascular benefits are liraglutide, subcutaneous semaglutide and dulaglutide.⁶⁰

Metformin should be considered in patients with T2D and ASCVD, unless contraindicated.¹² However, it is not a prerequisite for considering SGLT2i or GLP-1RA for cardiovascular benefits; in patients with T2D and ASCVD who are not already on metformin, SGLT2i and/or GLP-1RA should be considered first and metformin thereafter if additional blood glucose control is needed.⁶⁰ In patients who are already being treated with metformin, an SGLT2i and/or GLP-1RA should be considered independent of the need for additional blood glucose control.⁶⁰

Vaccination

Influenza vaccination given annually to patients with stable ASCVD is associated with reduced incidence of MI, improved HF prognosis and decreased cardiovascular risk in patients aged ≥65 years.^13,15 Furthermore, there is evidence to show that, when given early after an MI or in patients with high-risk ASCVD, influenza vaccine is associated with a lower risk of all-cause death and cardiovascular death at 12 months.¹⁵

Education Plan and Counselling Programme

A prospective cohort study in Thailand compared outcomes in a ‘control group’, comprising historical ACS patients who underwent PCI with usual care between October 2008 and May 2009, and a ‘case group’ of ACS patients who underwent PCI with usual care plus medical and educational checklists between May 2009 and January 2010.⁷⁰ The medical checklist consisted of medical review specifically for medications such as aspirin, clopidogrel, β-blocker and statin, whereas the educational checklist included healthcare education for smoking cessation, dietary control and physical activity; both checklists were deployed in addition to usual care at 24 hours after PCI, before discharge and at the 6-month follow-up.⁷⁰ The study found that in-hospital use of ACEIs and β-blockers was significantly higher in the case group than in the control group and remained higher at the 6-month follow-up; patients with diabetes and chronic kidney disease in the case group had better BP control according to the guideline.⁷⁰ Furthermore, 6-month readmission rates were significantly higher in the control group than in the case group.⁷⁰ The results from that and other studies highlight the importance of developing and following an educational plan and counselling programme in post-ACS patients for better outcomes.^70–72 The education plan should be comprehensive and individualised based on patient risk factors and comorbidities and should be consistently followed through. Counselling sessions should be extended to a patient’s caretakers or family members.

During the hospital stay, there are time constraints in effectively educating, counselling and implementing secondary prevention plans for patients and their caregivers. Hence, strong collaboration between healthcare professionals (including, but not limited to, cardiologists, rehabilitation specialists/nurses, dieticians, physiotherapists and pharmacists) is of utmost importance. A predischarge checklist (Supplementary Table 1) can help facilitate the preparation process before discharge.

The following key messages should be discussed and emphasised during counselling sessions:¹⁵

• A detailed explanation should be provided of the reason for the current hospitalisation, the diagnosis and test results, including any further need for revascularisation procedures.
• Education should be provided for the identification of warning symptoms (e.g. chest pain) for recurrent MI or other cardiovascular events, as well as guidance on what to do and whom to call if problems arise.
• An explanation should be given of the purpose of the prescribed medicine regimen, how to take the medications correctly (including dosage, frequency and duration) and how to refill prescriptions.
• Counselling should be provided for lifestyle modification to address/prevent risk factors.
• There should be discussion of the risks associated with delaying treatment and suboptimal adherence to medication and lifestyle modifications.
• The need for regular follow-up and monitoring of lipid profiles, BP and renal function should be emphasised.
• Psychological support or referral, if needed, should be provided.
• Information should be provided on how to optimise ‘heart health’ after ACS with an easy-to-understand infographic (Supplementary Figure 2).

Almost 50% of the respondents in our survey of cardiologists and interventional cardiologists in public and private practice in Thailand reported using patient education tools, with the most frequently used materials being appointment cards, ‘do’s and don’ts’ checklists and educational brochures (Supplementary Figure 1). Resource limitations and patient lifestyle and educational status were identified as some of the key barriers to achieving treatment goals in post-ACS patients (Supplementary Figure 1). The adoption and strict implementation of a post-discharge follow-up checklist (Supplementary Table 2) and collaboration with primary care practitioners and public health volunteers to help follow up with patients could potentially address some of these issues.

Cardiac Rehabilitation

Cardiac rehabilitation is the most effective way to administer a secondary prevention intervention.¹⁵ Cardiac rehabilitation in patients with a history of recent MI is associated with lower all-cause mortality rates, lower cardiovascular mortality rates and lower rehospitalisation (total, cardiovascular and non-cardiovascular).^73,74 A study conducted on patients with MI in Phatthalung Hospital in Thailand reported that 88.49% of patients were able to return to work after cardiac rehabilitation.⁷⁵

Although the benefits of comprehensive cardiac rehabilitation programmes have been proven, uptake (referral to and participation in) remains poor worldwide.^76,77 In Thailand, although 87% of new IHD patients who were diagnosed with coronary angiography had received health information, only 18% had participated in a cardiac rehabilitation programme.⁷⁶ Barriers to the uptake of cardiac rehabilitation programmes in Thailand include patient-related intrinsic factors, such as a lack of understanding of the benefits of cardiac rehabilitation, education levels and health literacy, a belief in the adequacy of home exercise and the severity of comorbidities, and extrinsic factors, such as cost and distance issues, access to facilities and inadequate communication from healthcare providers.⁷⁸ Based on these observations, we recommend that cardiologists and other relevant healthcare providers should endorse the benefits of cardiac rehabilitation to patients more strongly and clearly. In addition, home-based cardiac rehabilitation programmes with the support of trained community health volunteers can be offered to those who are unable to attend in-hospital programmes due to distance or health issues.

Timing of Initiation and Scope of Rehabilitation

Cardiac rehabilitation should be commenced as early as possible before hospital discharge or no later than 10 days after discharge.^15,35 It can be performed in either inpatient or outpatient settings and should be offered taking a patient’s age, comorbidities, frailty status and risk factors into consideration. The core component of cardiac rehabilitation should include: patient assessment, management and control of cardiovascular risk factors (including BP, lipid and T2D management); physical activity counselling; a prescription for exercise training; dietary advice; weight management; smoking cessation counselling; patient education; stress and psychosocial management; and vocational support.¹⁵

Physical Activity

It is recommended that all patients reduce sedentary time, which is an independent risk factor for all-cause mortality.¹⁵ For patients without a contraindication to exercise, an exercise regimen of ≥150 min/week of moderate-intensity aerobic activity is recommended to reduce hospital admission and mortality rates.¹³ A resistance exercise regimen of ≥2 days/week is recommended to improve muscle strength and cardiovascular risk factor control.¹³ Patients with low levels of habitual physical activity are also recommended to exercise at least 20–30 min daily to the point of slight breathlessness in order to gradually increase their exercise capacity.^13,35

Exercise training should form the pivotal part of comprehensive cardiac rehabilitation and should be offered to all patients, considering each patient’s age, pre-infarction physical activity level and physical limitations.^11,15 Daily physical activity should not replace participation in exercise-based cardiac rehabilitation.¹⁵

In Thailand, a study of new patients with IHD found that only 55.63% and 56.25% of patients engaged in physical activity before and after hospitalisation, respectively.⁷⁶ A quasi-experimental study conducted in patients discharged after coronary artery bypass grafts found that self-management programmes supported by nurses using telephone and web-based chat applications were effective in improving exercise adherence.⁷⁹

Weight and Dietary Management

Weight loss is indicated for patients who are classified as overweight or obese according to their BMI, and cut-off points for determining overweight and obesity have been recommended by the WHO, with lower cut-off points suggested for Asian populations.⁸⁰

It is recommended that patients adopt a more plant-based and less animal-based diet.¹⁵ The characteristics of a healthy diet as recommended by the ESC include increasing fruit and vegetable consumption (each to ≥200 g/day), increasing fibre intake (to 35–54 g/day, preferably from wholegrains), maintaining one to two servings of fish per week (one of which is an oily fish), maintaining consumption of 30 g unsalted nuts daily, limiting intake of lean meat, low-fat dairy products and liquid vegetable oils, minimising intake of processed meats, reducing intake of red meat to ≤300–500 g/week, reducing salt intake to ≤5 g/day, replacing saturated fats with polyunsaturated fats (the intake of saturated fats should only account for <10% of total energy intake), restricting alcohol consumption, avoiding trans unsaturated fats and processed food (<1% of total energy intake) and avoiding energy-dense foods such as sugar and sweetened soft drinks.^12,15

Smoking Cessation

Smoking is associated with an increased risk of reinfarction and mortality, including sudden cardiac death, after ACS.^81,82 Using a nationwide Thai PCI registry, Limpijankit et al. reported that current and ex-smokers were prone to developing earlier onset post-PCI MACE compared with non-smokers, and advocated for a smoking cessation program in these patients for prevention.⁸³ As such, smoking cessation interventions, including behavioural interventions, pharmacotherapy (e.g. varenicline, which is safe to use in ACS) and counselling, should be offered to all patients for the primary and secondary prevention of cardiovascular events.¹⁵

Current evidence suggests e-cigarettes are harmful to cardiovascular health because they increase BP, heart rate, arterial stiffness and vascular dysfunction similar to traditional tobacco cigarettes. The effects of e-cigarettes on successful smoking cessation remain inconclusive.^15,84

Long-term Care Plan

In addition to applying the best available evidence, clinical post-ACS management strategies should take into consideration patients’ preferences, needs and values.¹⁵ To ensure good clinical outcomes, healthcare professionals should:¹⁵

• practise shared decision-making with patients when appropriate;
• give clear, understandable information on treatment plans (including medication regimens and long-term lifestyle management) in simple terms; and
• use every encounter as an opportunity to engage and educate patients to be advocates for their own healthcare.

Optimum adherence to secondary prevention has been shown to be effective in improving clinical outcomes in post-ACS patients.^24,85,86 We recommend that clinicians familiarise themselves with various factors that are commonly associated with non-adherence and implement multimodal interventions to improve adherence, including early follow-up visits and continual engagement with patients.⁸⁷ Areas of focus for long-term prevention strategies should include:

• Adopting a total-risk management approach involves a multidisciplinary team which should include physicians, nurses, dietitians, pharmacists, exercise and occupational therapists, psychologists and social workers as appropriate, with due consideration of patient-related factors such as their health literacy, socioeconomic status, access to social support, and any cultural implications.
• Continuous communication among care team, patients and any caregivers, such as the use of a standardised checklist (e.g. a post-discharge checklist; Supplementary Table 2), personal telephone contact with patients every 3 weeks and monthly multidisciplinary team group discussion at a primary care facility.
• Ongoing individualised education for patients and any caregivers regarding symptom management, lifestyle modification and medication adherence.
• Consistent scheduling of follow-up visits to manage and stratify the patient’s risk of MACE (Table 1).

Standard quality monitoring tools should be used to measure patient outcomes and direct improvement of long-term prevention strategies. The tools could be in the form of a manual, such as a patient diary and patient cards, in addition to digital health applications or platforms.

Conclusion

Patients with ACS remain at very high risk of recurrent cardiovascular events or death, particularly within the first year after an initial ACS event. Despite the availability of international and local guidelines for the management of ACS, the control of risk factors after ACS and adherence to medications remain poor in Thailand and worldwide. There is an urgent need to standardise and implement pre- and post-discharge protocols and procedures, and to put in place long-term management plans to ensure that post-ACS patients do not experience repeat events/mortality and are able to regain their quality of life and functional capacities.

We hope our recommendations for the post-discharge management of patients with ACS, as well as the framework for a discharge protocol for the long-term management of post-ACS patients, will support clinicians across Thailand to optimise the care of their patients. Our recommendations are aimed at supporting general practitioners and general cardiologists across Thailand to manage patients with ACS, and we recommend that patients with complications secondary to MI or other complex comorbidities be referred to specialist cardiologists for appropriate management.

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