Annals of Clinical Cardiology

: 2021  |  Volume : 3  |  Issue : 1  |  Page : 8--13

Compliance with guideline-recommended management in patients with non-st-elevation acute coronary syndromes: Findings from the gulf COAST registry

Hamdan Alajmi1, Mohammad Zubaid2, Wafa Rashed3, Ibrahim Al-Zakwani4,  
1 Department of Cardiology, Sabah Al Ahmad Cardiac Center, Al Amiri Hospital, Kuwait City, Kuwait
2 Department of Internal Medicine with the Subspecialty of Cardiology, Mubarak Hospital, Kuwait City, Kuwait
3 Department of Internal Medicine with the Subspecialty of Cardiology, Mubarak Hospital, Kuwait City, Kuwait Oman, Kuwait
4 Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University; Gulf Health Research, Muscat, Oman

Correspondence Address:
Dr. Hamdan Alajmi
Department of Cardiology, Sabah Al Ahmad Cardiac Center, Al Amiri Hospital, Kuwait City


Background: Evaluation of management practices and adherence to treatment guidelines are essential components of improved health-care delivery. Despite the improvement in the implementation of guidelines, the medical management of acute coronary syndrome (ACS) remains suboptimal worldwide. The aim of the present study was to determine medication use patterns, recent trends, and prescription predictors of adherence to guideline-based therapies for non-ST-elevation ACS (NSTE-ACS) in the Middle East. Methods: We evaluated the use of a quadruple evidence-based medication (EBM) combination consisting of the concurrent use of dual antiplatelet therapy, β-blockers, and lipid-lowering agents at discharge among patients (n = 2782) with NSTE-ACS in four Middle Eastern countries. Results: A total of 56% (n = 1626) of the patients received all four guideline-recommended medications at hospital discharge. An adjusted model demonstrated that male sex, diabetes, dyslipidemia, prior percutaneous coronary intervention, prior myocardial infarction, prior coronary artery bypass graft, admission to a catheterization-equipped hospital, and smoking were positively correlated with EBM prescription on discharge. Conversely, cardiogenic shock, heart failure, renal impairment, higher GRACE risk score, and bleeding negatively correlated with concurrent use of the quadruple EBM combination. Conclusion: Nearly half of NSTE-ACS patients in the Middle East do not receive the quadruple EBM combination. Efforts are needed to bridge this gap between practice and guidelines.

How to cite this article:
Alajmi H, Zubaid M, Rashed W, Al-Zakwani I. Compliance with guideline-recommended management in patients with non-st-elevation acute coronary syndromes: Findings from the gulf COAST registry.Ann Clin Cardiol 2021;3:8-13

How to cite this URL:
Alajmi H, Zubaid M, Rashed W, Al-Zakwani I. Compliance with guideline-recommended management in patients with non-st-elevation acute coronary syndromes: Findings from the gulf COAST registry. Ann Clin Cardiol [serial online] 2021 [cited 2023 Feb 9 ];3:8-13
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Full Text


Ischemic heart disease (IHD) is the leading cause of death globally, accounting for approximately 11% of deaths in 2011.[1] There is a significant variation in IHD mortality rates among countries, with low- and middle-income countries accounting for more than 80% of cases of IHD mortality.[1] Many randomized controlled clinical trials along with a myriad of observational studies have shown the effectiveness of dual antiplatelets, β-blockers, and statins individually and combined in reducing short-and long-term mortality and morbidity in patients with non-ST-elevation acute coronary syndrome (NSTEACS).[2],[3],[4],[5],[6],[7],[8],[9]

An observational study of hospital care in patients with NSTE-ACS enrolled in the Can Rapid Risk Stratification of Unstable Angina (UA) Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association (ACC/AHA) Guidelines (CRUSADE) showed that every 10% increase in the prescription of guideline-recommended treatment was associated with a 10% reduction in inhospital mortality.[10] Consequently, evidence-based medications (EBMs) are Class I/IIA recommendations in the guidelines for the management of NSTE-ACS according to the ACC/AHA and the European Society of Cardiology (ESC).[11],[12],[13] However, due to the slow uptake of EBMs by clinicians, effective management of NSTE-ACS continues to be suboptimal, as there is still an adherence gap between the guidelines and real-life clinical practice.[14],[15],[16],[17]

Evaluation of management practices and adherence to treatment guidelines is essential for delivering better health care, and this is given Class 1 recommendations by the ESC.[18] A report from a Danish study stated that patients were less likely to be on optimal therapy post discharge if they were not prescribed EBMs upon discharge.[19] Therefore, the aim of the present study was to determine medication use patterns, recent trends, and prescription predictors of adherence to EBMs for NSTE-ACS in the Middle East.


Patient data from Gulf citizens with ACS events registry (Gulf COAST) were used for the present analysis. Gulf COAST was a prospective, observational, multicenter study on the management of all consecutive citizens admitted to 29 hospitals in 4 Gulf countries (Bahrain, Kuwait, the United Arab Emirates, and Oman) with a confirmed diagnosis of ACS from January 2012 to January 2013. A detailed methodology has already been published.[20] Patients who met the inclusion criteria ≥18 years, diagnosed with ACS, consented for enrollment, and a Gulf citizen were enrolled. Standardized case report forms (CRFs) were prospectively filled and then entered into an online database. Data were reported in accordance with the ACC key data elements and definitions.[21] Each CRF included demographics, past medical history, conventional risk factors, smoking history, prior medication, inhospital treatments and course, discharge medication, and inpatient cardiac catheterization and intervention.

Of 4044 ACS patients included in Gulf COAST, 3009 patients were diagnosed with NSTE-ACS (1103 with UA and 1906 with NSTE myocardial infarction [MI]). Discharge medications were not documented for 95 patients who died during the hospital stay or for 107 patients who left the hospital against medical advice. In addition, data on discharge medications were missing in 25 other patients. After exclusion of all patients with either undocumented or missing data on discharge medications, 2782 remaining patients were included in this study.

For the purpose of the present analysis, patients who were admitted with NSTE-ACS were stratified into two groups based on the prescription of the quadruple EBM combination of acetylsalicylic acid, clopidogrel, β-blockers, and statins at discharge.

Statistical analysis

For categorical variables, frequencies and percentages were reported. Differences between groups were analyzed using Pearson's χ2 test (or Fisher's exact test for expected cells <5). Continuous variables were presented as the means and standard deviations, and analyses were performed using Student's t-test. The association between the concurrent use of EBMs and various predictors was analyzed using multivariable logistic regression. The a priori two-tailed level of significance was set at P < 0.05. STATA version 13.1 (STATA Corporation, College Station, TX, USA) was used to conduct statistical analysis.


The baseline characteristics of 2782 NSTE-ACS patients according to prescription of EBMs upon discharge are shown in [Table 1]. The overall mean age of the patients in the study cohort was 60 ± 12 years, and 62% (n = 1,730) were male. Regarding cardiovascular risk factors, 71% (n = 1,976) of patients were hypertensive, 61% (n = 1,711) had dyslipidemia, and 56% (n = 1,570) had diabetes mellitus. For prior coronary artery disease, just under 13 (n = 853) reported a history of MI, 15% (n = 414) had a history of heart failure (HF), 25% (n = 702) had percutaneous coronary intervention (PCI), and 8% (n = 248) had coronary artery bypass graft (CABG) surgery.{Table 1}

Patients who received quadruple EBM therapy were more likely to be male (67% vs. 56%; P < 0.001), be a smoker (23% vs. 16%; P < 0.001), have diabetes mellitus (59% vs. 53%; P = 0.003), have dyslipidemia (65% vs. 56%; P < 0.001), have a history of prior MI (33% vs. 26%; P < 0.001), have undergone prior PCI (29% vs. 20%; P < 0.001), and have undergone prior CABG (10% vs. 7%; P = 0.010). Furthermore, patients who were admitted to hospitals equipped with catheterization labs were more likely to receive the combination EBM regimen upon discharge (49% vs. 27%; P < 0.001) than those not admitted to hospitals equipped with catheterization laboratories. In contrast, NSTE-ACS patients who had a high-risk presentation (HF, cardiogenic shock, higher Killip class, higher GRACE score) or who had adverse hospital outcomes (HF, cardiogenic shock, bleeding) were less likely to receive the EBM regimen concurrently.

As shown in [Table 2], overall, 56% (n = 1,626) of patients received all four guideline-recommended medicines at hospital discharge. Guideline adherence for individual medicines was 96% for both acetylsalicylic acid and statins, 84% for β-blockers, and 70% for clopidogrel.{Table 2}

The associations between the concurrent use of all EBMs and various predictors were analyzed using multivariable logistic regression [Table 3]. Male sex, diabetes mellitus, dyslipidemia, prior PCI, prior MI, prior CABG, admission to catheterization-equipped hospitals, and smoking were positively correlated with EBM prescription on discharge. Conversely, cardiogenic shock, HF, higher GRACE risk score and Killip class score, and bleeding were negatively correlated with concurrent use of the quadruple EBM combination.{Table 3}


Our study provides important insights into the pharmacological management of NSTE-ACS in the Arabian Gulf region of the Middle East. Patients with NSTE-ACS had a mean age of 60 years, were predominantly male, and frequently had chronic comorbidities (hypertension, dyslipidemia, and diabetes mellitus). Our NSTE-ACS patients, in comparison with patients in other registries, were 5 years younger and had a higher prevalence of risk factors, especially diabetes mellitus.[22],[23],[24],[25] This could be explained by oil wealth-induced obesogenic urbanization, leading to a sedentary life and consumption of a Western diet.

The present study revealed that the percentages of patients who received all four guideline-recommended classes and all five guideline-recommended classes of pharmacological agents at discharge were 58% and 48%, respectively. Individual utilization rates for aspirin, thienopyridine, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), and statins at hospital discharge were 96%, 70%, 84%, 79%, and 96%, respectively. The low rate of ACEI/ARB prescription is related to the IIb recommendation classification unless there is diabetes, hypertension, ejection fraction (EF) <40%, or renal impairment, and this could be an indirect indication of the physicians' awareness of the guidelines.

The first conclusion of our study is that, after evaluating other registries in the Arabian Gulf, there is a temporal improvement in the use of evidence-based pharmacologic therapies in our region. Compared to the Gulf Registry of Acute Coronary Events (Gulf RACE I), there was a time-related increase in utility in the medical management of patients discharged with NSTE-ACS.[26] In Gulf RACE I, the usage rates of acetylsalicylic acid, statins, clopidogrel, β-blockers, and ACEI/ARB were 94%, 81%, 50%, 75%, and 69%, respectively. Moreover, in the Gulf RACE II study, the utilization of optimal medical therapy was comparable to our findings.[27] This higher rate of guideline adherence in our region is encouraging and may suggest that compliance with guideline-based therapy has improved significantly over the past several years across the region. It is worth noting that the prescription rate of β-blockers, statins, and clopidogrel has improved dramatically when compared to the prescription rates of aspirin and ACEI/ARB. This suggests that over time, physicians may have become less hesitant to prescribe these medications because drug safety profiles are better understood, recognized the importance of treating diabetes with lipid-lowering agents, and been more inclined to prescribe them to elderly patients.

Our data are favorable compared to data reported in other geographic regions, especially developed countries, as similar trends have been reported by other ACS registries. First, the Canadian ACS registry showed a temporal increase in medication use in Canada, as the percentage of patients who received the optimal medical therapy upon discharge in the ACS I registry was 28.9% in 2001 and 51.8% in 2003.[28] Furthermore, compared to the CRUSADE initiative, the utilization of medical therapy at discharge observed in our study was almost identical or even higher, which further confirms the idea of the comparability of our practice to those in developed countries and provides robust proof of the improvement in adherence to the guideline recommendations in our region.[29] In this observational study, the individual medication use in 2004 was 63.7% for ACEIs/ARBs, 94.7% for acetylsalicylic acid, 88.8% for β-blockers, 68.7% for clopidogrel, and 86.8% for statins, while in 2002, the discharge medication utilization rates were 88.9% for aspirin, 50% for clopidogrel, 81% for β-blockers, 77.7% for statins, and 59% for ACEIs/ARBs.

Second, the present study finding resembles the finding from a systematic literature review regarding the influential effect of the patient and the organization characteristics on the discharge medications.[30] Similar to our results, the following patient-related factors were associated with higher prescription rates of discharge medications in the aforementioned literature review: high blood pressure on admission, dyslipidemia, smoking, angina pectoris, peripheral artery disease, prior PCI, prior CABG, prior MI, diabetes mellitus, prior clopidogrel use, risk factors for coronary artery disease, and inhospital coronary angiogram. This indicates that the regional physicians understand the guidelines and the need to adhere to ongoing guideline updates. However, it also showed comparable findings regarding factors that lower the prescription rate, such as female sex, high heart rate on admission, chronic HF, high GRACE risk status, EF <40%, bleeding, and inhospital cardiogenic shock.

Even though guidelines recommend optimal medical therapy regardless of the available intervention (surgical, PCI, or medical), the Arabian Gulf COAST registry has shown that admission to hospitals with onsite catheterization facilities was the strongest predictor of guideline-adherent medication prescription at discharge. This was also noted in the Dutch CCR, Canadian ACS I and ACS II, and Gulf RACE II registries, as patients who were admitted to interventional centers were more likely to be discharged with prescriptions for all 5 EBMs.[27],[31],[32] The influence of coronary catheterization can also be seen in the German EPICOR registry, which showed that NSTE-ACS patients were discharged on ACEI (89.5%), aspirin (95.2%), β-blockers (91.3%), thienopyridine (83.2%) (62.8% clopidogrel/20% prasugrel), and statins (92.2%).[33]

One explanation for this substantial effect of onsite catheterization facilities on discharge medications is indicated by a study that showed that NSTE-ACS patients tend to be treated in small hospitals and are less likely to be treated in academic hospitals, reflecting some referral bias. Furthermore, hospitals that provide primary PCI may be better situated from a programmatic viewpoint to have the structure to adhere to evidence-based practice than centers without continuous interventional capabilities.[34]

Interestingly, the use of guideline-adherent pharmacotherapy was paradoxically lower in patients at high risk for future cardiovascular events. The higher the GRACE score, the less likely a patient is to be discharged on optimal therapy. The probable explanation is that Killip class and low EF are important variables that were negatively associated with the optimal therapy at discharge. Furthermore, even though determining the factors that influence physician decisions is difficult, physicians' behaviors and beliefs, such as “risk-averse” behavior and “therapeutic nihilism,” which means prescribing an indicated medication to patients with poor outcomes would be ineffective, might also play a crucial role in physicians' decisions in prescribing discharge medications. One study, which examined the reasons behind nonadherence to the guidelines, found that a considerable proportion of patients were not given the required treatment for no precise reason.[35]

Unfortunately, the negative association of female sex with guideline adherence was obvious in our study. This is consistent with other studies and is worrisome, as the most recent guidelines recommend managing both sexes in the same way.[30],[36] To our knowledge, there is limited information on the impact of sex on the decision of physicians to prescribe secondary prevention medications after an ACS event.

One of the strong limitations in our study is that there was insufficient information in the patient CRFs to identify reasons for incomplete therapy, and because of the retrospective nature of our study, we could not collect additional information on this aspect. This study was conducted in 2012 based on previous guidelines that underwent frequent updates before being replaced by the latest guidelines even though they are largely similar. Furthermore, adherence to the guidelines means prescribing the medications unless contraindicated. Therefore, the adherence to the guidelines could have been higher if contraindications had been reported in the CRFs. However, contraindications and adverse effects of EBMs were not reported. A report from a study conducted in Switzerland showed high adherence to ACS guidelines for drug prescriptions when they included reasons for nonprescription to drug therapy, such as side effects and contraindications.[37]


Despite the improvement in utilization of guidelines in our region, the medical management of ACS remains suboptimal worldwide, and there is room for improvement of care by adapting to the up-to-date guidelines. The ESC guidelines stress the importance of the development of regional and/or national programs to systematically measure performance indicators that can provide feedback and focus future quality improvement efforts on reducing variation between patient groups and hospitals. In our region, improved guideline adherence can be achieved by developing quality control programs or joining existing programs along with establishing a culture that encourages utilization of all necessary measures to improve patient outcomes.

Consent for publication

All authors have read and given their consent. No objection for publishing the data.

Financial support and sponsorship


Competing interests

There are no conflicts of interest.


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