Tropical Medicine and International Health doi:10.1111/tmi.

12467

volume 20 no 5 pp 627–637 may 2015

Physicians’ adherence to acute coronary syndrome prescribing

guidelines in Vietnamese hospital practice: a cross-sectional
study
Thang Nguyen1,2, Thao H. Nguyen2,3, Hoa T. K. Pham4, Thu T. A. Nguyen5, Khoa M. Huynh3,
Phuong T. B. Vo3, Tam T. Pham6 and Katja Taxis2

1 Department of Pharmacology and Clinical Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
2 Department of Pharmacy, Unit of Pharmacotherapy and Pharmaceutical Care, University of Groningen, Groningen,
The Netherlands
3 Department of Clinical Pharmacy, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
4 Cardiology Department, Can Tho General Hospital, Can Tho, Vietnam
5 Cardiology Hospital, Ho Chi Minh City, Vietnam
6 Faculty of Public Health, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam

Abstract objectives To determine the extent of physicians’ adherence to prescribing guidelines for acute
coronary syndrome in Vietnamese hospitals.
methods Retrospective cross-sectional study of medical records of all patients with ACS admitted
to two public hospitals in Ho Chi Minh City, Vietnam, from January to December 2013. Percentages
of eligible patients receiving guideline-recommended medications were determined. Factors associated
with non-adherence were identified using multivariate logistic regression.
results Overall, 711 medical records were reviewed and 284 patients fulfilled inclusion criteria
(mean age 64 years; 69.4% male). Of those patients eligible for treatment, aspirin was prescribed for
97.9% at arrival and 96.3% at discharge; dual antiplatelet therapy was prescribed for 92.3% at
arrival and 91.7% at discharge; loading doses were prescribed for 79.5% (aspirin) and 55.8%
(clopidogrel); beta blockers were prescribed for 58.7% at arrival and 76.7% at discharge;
angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEI/ARB) were
prescribed for 89.1% at arrival or discharge; and statins were prescribed for 94.1% at arrival and
90.7% at discharge. Patients undergoing an invasive procedure were more likely to receive guideline-
recommended medications at discharge: dual antiplatelet therapy (OR 3.77; 95% CI 1.23–11.52),
beta blocker (OR 3.95; 95% CI 1.86–8.40) and ACEI/ARB (OR 4.01; 95% CI 1.30–12.41). Ninety
of the excluded patients were discharged without completing treatment.
conclusions In general, physicians closely adhered to ACS prescribing guidelines in Vietnamese
hospital practice. Prescribing of beta blockers and clopidogrel loading doses was probably
suboptimal. Why patients do not complete treatment needs to be investigated.

keywords acute coronary syndrome, adherence, guideline, prescribing, Vietnam

wave) myocardial infarction (STEMI), non-ST elevation

Introduction
(formerly non-Q wave) myocardial infarction (NSTEMI)
Ischaemic heart disease (IHD) is among the leading and unstable angina (UA) [3].
causes of death worldwide. In 2008, 7.3 million people International guidelines recommend using a combina-
died due to IHD (12.7% of total global mortality) [1]. tion of two antiplatelet agents (aspirin plus clopidogrel),
Low- and middle-income countries accounted for more a beta blocker, an angiotensin-converting enzyme inhibi-
than 80% of those [1]. IHD comprises a spectrum of dis- tor or an angiotensin II receptor blocker (ACEI/ARB) and
eases of the heart including acute coronary syndrome an HMG coenzyme A reductase inhibitor (statin) to treat
(ACS), which is the main cause of IHD deaths [2]. patients with ACS [3–7]. This regimen reduces in-hospital
Patients with ACS suffer from myocardial ischaemia. and post-discharge mortality rates in patients with ACS
There are three types of ACS: ST elevation (formerly Q [8, 9]. An observational study of almost 65 000 patients

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

with NSTEMI showed that every 10% increase in adher- initially and were transferred to the study site conse-
ence to prescribe guideline-recommended treatment was quently; [2] who did not fully complete treatment (i.e.
associated with a 10% reduction in in-hospital mortality patients who were transferred to another hospital for fur-
(adjusted odds ratio 0.90, 95% CI 0.84–0.97). In-hospital ther treatment or patients who were discharged with or
mortality was significantly lower in the hospitals with the without permission of their physician when the therapy
highest than in hospitals with the lowest adherence quar- was incomplete); or [3] with missing data of arrival or
tile (4.2% vs. 6.3%) [9]. Despite such evidence, adher- discharge medications in their medical records.
ence to guidelines remains suboptimal [10–15], in All medical records of patients with a diagnosis of
particular, in low- and middle-income countries [16–18]. angina or ACS (I20, I21 and I22) were requested from
Shimony et al. [17] showed that patients from high- the hospital record archives. Information from medical
income countries (Canada and United States) were more records was extracted by two researchers (KMH and
likely to receive guideline-recommended medications at PTBV) using a pre-defined data collection form. Data
discharge (OR 2.32, 95% CI 1.19–4.52, a combination included: age, sex, health insurance, length of hospital
of aspirin, clopidogrel and a statin) than those in low- stay, coronary artery disease risk factors, medical history
and middle-income countries (India, Iran, Pakistan and of myocardial infarction, invasive procedures [including
Tunisia). percutaneous coronary intervention (PCI) and coronary
In Vietnam, ischaemic heart disease was one of the artery bypass grafting (CABG)], comorbidities (peptic
major leading causes of death across all ages in 2007 ulcer, asthma/COPD, renal failure, hepatic failure and
[19]. The Vietnam National Heart Association (VNHA) heart failure), in-hospital revascularisation [invasive pro-
published the first guidelines on management of ACS in cedure (PCI or CABG) or non-invasive procedure (with
2006 with an update in 2008 [20]. VNHA guidelines are or without fibrinolysis)], Global Registry of Acute Coro-
in line with international guidelines in their recommenda- nary Events prediction score for all-cause mortality in the
tions of prescribing evidence-based medications [3–7, 20]. first 6 months after discharge (GRACE score) [22] and
However, in contrast to some other Asian countries, little laboratory examinations. Details of all medications pre-
is known about the prescribing patterns for patients with scribed within the first 24 h after hospital admission and
ACS during hospitalisation and after discharge in Viet- at hospital discharge were collected (brand and generic
namese hospitals. Therefore, we determined the extent of name of the medication, dose, dosage form, administra-
physicians’ adherence to acute coronary syndrome (ACS) tion route and frequency of administration). Information
prescribing guidelines in Vietnamese hospital practice. on contraindications to antiplatelet therapy, beta block-
ers, ACEI/ARBs or statins was also recorded.
Data were analysed [1] to determine the percentages of
Method
eligible patients who were prescribed guideline-recom-
A retrospective cross-sectional study was performed of all mended medications during the first 24 h of hospitalisa-
patients admitted with a diagnosis of ACS between Janu- tion and at hospital discharge and [2] to identify factors
ary and December 2013 to two public hospitals at pro- associated with non-adherence to prescribing guideline-
vincial level: one comprising 1200 beds (Hospital A), and recommended medications.
one with 700 beds (Hospital B). Study wards were as fol- Guidelines used in this study were the current version
lows: cardiology, internal medicine, intensive care unit of the Vietnam National Heart Association (VNHA),
and cardiac intensive care unit. On the cardiology wards, the European Society of Cardiology (ESC) and the
Hospital A employed 26 physicians and had 52 beds; and American College of Cardiology/American Heart Associ-
Hospital B employed 14 physicians and had 60 beds. ation (ACC/AHA). All three guidelines recommend use
Invasive procedures could be performed in both of two antiplatelet agents (aspirin and clopidogrel), a
hospitals. beta blocker, an ACEI/ARB and a statin within the first
We included patients who survived during hospitalisa- 24 h after hospital admission (hereafter called ‘at arri-
tion with one of the following discharge diagnoses val’) and at hospital discharge. This is a class I recom-
according to coding of the International Classification of mendation, that is the treatment should be given
Diseases, 10th revision (ICD-10): unstable angina (I20.0), because of its benefit, usefulness or efficacy and sup-
acute myocardial infarction (I21) or subsequent myocar- ported by a high level of evidence (level A, data derived
dial infarction (I22) [21]. For patients who were admitted from multiple randomised clinical trials or meta-analy-
several times during the study period, we only included sis; or level B, data derived from a single randomised or
the medical record of the first admission. We excluded large non-randomised studies), with the exception of
patients [1] who had been admitted to another hospital prescribing ACEI/ARB at arrival (not recommended in

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

the ESC guidelines) or statin at arrival (not recom- Data were analysed using the Statistical Package for
mended in ACC/AHA guidelines and VNHA guideline the Social Sciences, version 20th (SPSS 20). Multivariate
for STEMI) (Appendix 1) [3–7, 20]. logistic regression with forward stepwise method was
The percentage of eligible patients receiving a guide- performed to identify potential factors associated with
line-recommended medication was calculated by dividing guideline non-adherence at arrival or discharge. The fol-
the number of eligible patients who were prescribed the lowing variables were included in the multivariate model:
medication by the total number of eligible patients who age group (age ≥65 vs. <65 years); sex (male vs. female);
should be prescribed the medication, multiplied by 100. diagnosis (NSTEMI vs. UA and STEMI vs. UA), health
Eligible patients for being prescribed aspirin, a loading insurance; previously diagnosed diabetes mellitus, hyper-
dose of aspirin, dual antiplatelet therapy, a beta blocker tension, dyslipidemia, myocardial infarction and heart
or a statin were patients without contraindications to the failure; in-hospital revascularisation (invasive vs. non-
medications. Eligible patients for being prescribed a load- invasive procedure) (only for discharge recommenda-
ing dose of clopidogrel were patients younger than tions); GRACE score (moderate vs. low risk and high vs.
75 years of age without contraindications to clopidogrel. low risk) (only for discharge recommendations); and
Eligible patients for being prescribed an ACEI/ARB were number of discharge medications (>6 vs. ≤6 medications)
patients with heart failure, a left ventricular ejection frac- (only for discharge recommendations). Patients with doc-
tion (LVEF) <40%, diabetes mellitus, or hypertension umented contraindications to the studied agents were
and without contraindications to ACEI/ARBs. Contrain- excluded from this analysis.
dications were based on the current guidelines [4–7, 20],
AHFS Drug Information (2012) [23], Facts and Compari-
Results
sons (2013) [24] and the Vietnamese National Formulary
(2012) [25] (Appendix 2). A patient with ACS and no A total of 711 medical records of patients with a diagno-
relevant contraindications was likely to be prescribed the sis of angina or ACS were identified and 284 patients
following six discharge medications: two antiplatelet were included in the study (Figure 1). The following
agents (aspirin and clopidogrel), a beta blocker, an ACEI/ medical records were excluded: 270 records of patients
ARB, a statin and a proton pump inhibitor (protection with a discharge diagnosis of unspecified angina or stable
against gastrointestinal side effects of antiplatelet angina, and 7 records of second admissions; and 150
therapy). records because of exclusion criteria: 60 patients who

Medical records of ACS or Medical records of ACS or

angina patients of hospital A angina patients of hospital B
in 2013 (N = 417) in 2013 (N = 294)

- Unspecified angina or
stable angina (n = 270)
- Second admission
Number of patients reviewed cases (n = 7)
N = 434
Excluded (n = 150)
1.Transferred from the other
hospitals (n = 60)
2.Incomplete therapies (n = 90)
3.Missing data (n = 0)

Number of patients included

N = 284

Unstable angina NSTEMI STEMI

N = 55 (19.4%) N =113 (39.8%) N = 116 (40.8%)

Figure 1 Flowchart of study population.

ACS, acute coronary syndrome; NSTEMI, Non-ST elevation myocardial infarction; STEMI, ST elevation myocardial infarction.

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

had been admitted to another hospital initially and were (Table 1). The majority of patients were male (69.4%)
transferred to the study site consequently, 90 patients and had hypertension (67%). Fifty-five (18.7%) reported
who did not fully complete treatment therapy: 13 were prior MI and 22 (7.7%) had prior PCI; 128 (45.1%)
transferred to another hospital for further treatment, 61 patients underwent PCI, 4 (1.4%) underwent CABG, and
were discharged with permission of their physician when 152 (53.5%) had no invasive procedure and received
the therapy was incomplete, and 16 without physician pharmacological treatment with fibrinolysis (3 patients)
permission. or without fibrinolysis (149 patients); and 191 (67.3%)
The patients had a mean age of 64 years (range 30 to patients had a moderate or high risk and 85 (29.9%) had
105 years); 47% of the patients were over 65 years old a low risk of death within 6 months after hospital

Table 1 Patient characteristics

Type of ACS

Patient characteristic Overall (n = 284) UA (n = 55) NSTEMI (n = 113) STEMI (n = 116)

Demographics and general characteristics

Mean age (SD) 64.2 (14.1) 63.6 (11.5) 67.7 (14.9) 61.0 (13.6)
Age range 30–105 39–88 30–105 33–97
Male 197 (69.4) 37 (67.3) 64 (57.1) 94 (81.7)
Insurance 176 (62) 46 (83.6) 71 (63.4) 58 (50.4)
Length of hospital stay (days) 8 (1–41) 7 (2–38) 10 (1–41) 7 (2–40)
Number of medications at discharge 6.9 (1.5) 6.7 (1.4) 7.4 (1.6) 6.6 (1.4)
Number of discharge medications >6 158 (55.6) 29 (52.7) 75 (66.4) 54 (46.6)
CAD risk factors
CAD family history 12 (4.2) 3 (5.5) 6 (5.3) 3 (2.6)
Hypertension 193 (68) 42 (76.4) 84 (74.3) 67 (57.8)
Diabetes 71 (25) 15 (27.3) 37 (32.7) 19 (16.4)
Dyslipidemia 47 (16.5) 9 (16.4) 27 (23.9) 11 (9.5)
Smoking 99 (34.9) 12 (21.8) 34 (30.1) 53 (45.7)
CRP/fibrinogen increase 119 (41.9) 9 (16.4) 56 (49.6) 54 (46.6)
Age ≥65 136 (47.9) 23 (41.8) 66 (58.4) 47 (40.5)
Menopause 85 (29.9) 17 (30.9) 48 (42.5) 20 (17.2)
Medical history and comorbidities
Prior MI 55 (18.7) 20 (36.4) 28 (24.8) 5 (4.3)
Prior undergone invasive procedure 24 (8.5) 7 (12.7) 9 (8) 9 (6.9)
Peptic ulcer 28 (9.9) 3 (5.5) 10 (8.8) 15 (12.9)
Asthma/COPD 20 (7) 4 (7.3) 12 (10.6) 4 (3.4)
Renal failure 33 (11.6) 7 (12.7) 21 (18.6) 5 (4.3)
Hepatic failure 5 (1.8) 0 2 (1.8) 3 (2.6)
Heart failure 69 (24.3) 7 (12.7) 45 (39.8) 17 (14.7)
In-hospital revascularisation
Invasive 132 (46.5) 14 (25.5) 37 (32.7) 81 (69.8)
PCI 128 (45.1) 14 (25.5) 33 (29.2) 81 (69.8)
CABG 4 (1.4) 0 4 (3.5) 0
Non-invasive 152 (53.5) 41 (74.5) 76 (67.3) 35 (30.2)
With fibrinolysis 3 (1.1) 0 0 3 (2.6)
Without fibrinolysis 149 (52.5) 41 (74.5) 76 (67.3) 32 (27.6)
GRACE score
Low risk 85 (29.9) 17 (30.9) 21 (18.6) 47 (40.5)
Moderate risk 74 (26.1) 21 (38.2) 22 (19.5) 31 (26.7)
High risk 117 (41.2) 15 (27.3) 66 (58.4) 36 (31.0)
Missing data 8 (2.8) 2 (3.6) 4 (3.5) 2 (1.7)

ACS, acute coronary syndrome; CABG, coronary artery bypass grafting; CAD, coronary artery disease; COPD, chronic obstructive pul-
monary disease; CRP, C-reactive protein; GRACE, Global Registry of Acute Coronary Events; MI, myocardial infarction; NSTEMI,
non-ST elevation myocardial infarction; PCI, percutaneous coronary intervention; SD, standard deviation; STEMI, ST elevation myo-
cardial infarction; UA, unstable angina.

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

discharge. The risk of the remaining patients remained were systolic blood pressure less than 100 mmHg, aortic
unknown because of missing data. valve stenosis, or glomerular filtration rate (GFR) less
Aspirin was prescribed for 97.9% of eligible patients than 30 ml/min. Patients were less likely to receive an
at arrival and 96.3% at discharge (Table 2). Fewer ACEI/ARB at hospital discharge when they had no inva-
patients received an aspirin loading dose (79.5%) and a sive procedure (Table 3).
clopidogrel loading dose (55.8%). Documented contrain- Statins were prescribed for 94.1% of eligible patients
dications for antiplatelet agents were intracranial haem- at arrival and 90.7% at discharge (Table 2). Documented
orrhage, gastrointestinal (GI) bleeding, bleeding contraindications to statins were elevations of hepatic
disorders, active GI ulcer or asthma/chronic obstructive transaminases (3 times higher than the upper normal lim-
pulmonary disease (COPD). Multivariate analysis showed its). No factor was significantly associated with non-
that dual antiplatelet therapy at discharge was more adherence to prescribing statins.
frequently given to patients who underwent an invasive
procedure during hospitalisation or who received more
Discussion
than six discharge medications. Patients with STEMI
were more likely than UA to receive an aspirin loading Our study provides insight into pharmacological manage-
dose (Table 3). No factor was significantly associated ment of ACS at arrival and discharge from two Vietnam-
with non-adherence to prescribing a loading dose of ese hospitals. In line with previous studies, patients with
clopidogrel. ACS in our study had a mean age above 60 years, were
Beta blockers were prescribed for 58.7% of eligible predominantly male and frequently had chronic comor-
patients at arrival and 76.7% at discharge (Table 2). bidities (hypertension, dyslipidemia and diabetes mellitus)
Documented contraindications to beta blockers were [16, 26–28]. In general, physicians prescribed guideline-
signs of heart failure, evidence of low output state, car- recommended medications. Patients who underwent an
diogenic shock, second- or third-degree heart block or invasive procedure were more likely to receive evidence-
asthma. Patients with heart failure, STEMI (compared to based medications (aspirin plus clopidogrel, beta blocker,
UA), or female patients were less likely to receive a beta ACEI/ARB) at discharge. This was encouraging, but more
blocker at arrival. Patients were less frequently prescribed eligible patients with ACS not undergoing an invasive
a beta blocker at discharge when they had no invasive procedure should receive the combination treatment [3–7,
procedure or when they had an NSTEMI (compared to 20]. When our results were compared to the figures of
UA) (Table 3). other low- and middle-income countries in several previ-
ACEI/ARBs were prescribed for 89.1% of eligible ous studies [16, 17], adherence to guidelines seemed rela-
patients at arrival or at discharge (Table 2). Documented tively higher for antiplatelet therapy, ACEI/ARBs and
contraindications in patients not receiving an ACEI/ARB statins, but lower for beta blockers.

Table 2 Utilisation of guideline-recommended medications

Guideline Number of eligible patients receiving Number of Percentage of eligible patients receiving
recommendation guideline-recommended medication eligible patients guideline-recommended medication

At arrival
Aspirin 191 195 97.9
Dual antiplatelet therapy 179 194 92.3
Aspirin loading dose 155 195 79.5
Clopidogrel loading dose 82 147 55.8
Beta blocker 84 143 58.7
ACEI/ARB 164 184 89.1
Statin 241 256 94.1
At discharge
Aspirin 208 216 96.3
Dual antiplatelet therapy 198 216 91.7
Beta blocker 168 219 76.7
ACEI/ARB 171 192 89.1
Statin 253 279 90.7

ACEI/ARB, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker.

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

Table 3 Factors associated with guideline non-adherence*

Number of patients Number of patients

receiving NOT receiving
guideline-recommended guideline-recommended
Factor medication (%) medication (%) OR 95% CI P-value

Aspirin loading STEMI† 76 (49.0) 7 (17.5) 6.1 2.2–17.0 0.001

dose at arrival
Beta blocker Male 70 (83.3) 36 (61.0) 3.6 1.5–8.7 0.004
at arrival STEMI† 17 (28.8) 31 (52.5) 0.3 0.1–0.9 0.022
Heart failure 3 (3.6) 11 (18.6) 0.2 0.1–0.8 0.026
Dual antiplatelet Invasive 97 (49.0) 5 (27.8) 3.8 1.2–11.5 0.020
at discharge procedure
Discharge 110 (55.6) 5 (27.8) 4.6 1.5–14.0 0.007
medications >6
Beta blocker NSTEMI† 54 (32.1) 28 (54.9) 0.3 0.1–0.7 0.007
at discharge Invasive procedure 96 (57.1) 14 (27.5) 4.0 1.9–8.4 <0.001
ACEI/ARB Invasive procedure 83 (48.5) 4 (19.0) 4.0 1.3–12.4 <0.001
at discharge

*Using multivariate logistic regression with forward stepwise method.

†Compared to UA; ACEI/ARB, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker; CI, confidence interval;
NSTEMI, non-ST elevation myocardial infarction; OR, odds ratio; STEMI, ST elevation myocardial infarction.

Almost all eligible patients were prescribed aspirin at be re-evaluated during hospital stay for beta blocker can-
arrival and discharge and most patients received dual an- didacy because of well-established benefits of beta block-
tiplatelet therapy. These findings are similar to many ers for secondary prevention [4–7, 20, 43, 44].
other studies from around the world [27–31]. Aspirin Prescribing beta blockers should be, therefore, improved
plays an essential role in ACS treatment [32, 33]. There focusing on female patients and patients with heart fail-
is also much evidence to give a P2Y12 receptor blocker ure or STEMI. Finally, we observed higher rates of using
(e.g. clopidogrel) in addition to aspirin for up to 1 year ACEI/ARBs and statins than previous studies [28–31].
following an ACS [34–36], but physicians may have con- This is encouraging as recommendations in guidelines are
cerns about the benefit-risk ratio and extra cost of the based on several trials supporting the role of ACEI/ARBs
second antiplatelet agent clopidogrel. We observed a con- (ISIS-4, GISSI-3 trials, etc.) and statins (PROVE-IT TMI
siderable lower rate of prescribing aspirin and clopidogrel 22, MIRACL, A to Z trials, etc.) in the management of
loading doses, especially in patients with UA. Guidelines patients with ACS [45–49].
recommend to give a loading dose of aspirin as soon as Our study has several limitations that merit consider-
possible to any patient thought to have an ACS (UA, ation. First, failure to adequately document clinical infor-
NSTEMI or STEMI) and add a clopidogrel loading dose mation in medical records may influence our results. In
in patients younger than 75 years of age [3–7, 20, 37– particular, failure to document contraindications may
39]. Further work needs to investigate reasons for not have led to misclassify some patients as being eligible for
following this advice. a certain treatment. Second, due to administrative rea-
The percentage of patients prescribed beta blockers at sons, we had to exclude cases of patients who died dur-
arrival was suboptimal and lower than observed in some ing hospitalisation, so our results are not generalisable to
other studies (65–83%) [40–42]. Multivariate analysis this patient group. Third, we also had to exclude a large
showed that patients with STEMI (compared to UA), number of patients who were discharged home although
heart failure or female patients were less likely to receive their therapy was incomplete. We believe that patients
beta blockers at arrival. Underutilisation of beta blockers, with incomplete therapy were either of advanced age
especially at arrival, may be because of physicians’ con- and/or severely ill, so physicians considered that treat-
cerns about adverse reactions of beta blockers in patients ment was no longer beneficial or could not pay for fur-
with comorbidities such as diabetes mellitus or heart fail- ther hospital treatment probably because of not being
ure. The initiation of oral beta blockers at arrival is rec- insured. There was insufficient information in the medical
ommended for all ACS patients without notes to identify reasons for incomplete therapy, and
contraindications. Patients with contraindications should because of the retrospective nature of our study, we could

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

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Appendix 1 Guideline recommendations for acute coronary syndrome treatment*

Class and level of guideline recommendations

VNHA ACC/AHA ESC

Guideline
recommendation Description NSTEACS STEACS NSTEACS STEACS NSTEACS STEACS

At arrival
Aspirin at arrival ACS patients without aspirin I I I-A I-A I-A I-A
contraindications who received
aspirin within the first 24 h
after hospital admission
Dual antiplatelet ACS patients without contraindications I I I-B I-B I-A I-A
therapy at arrival of aspirin and clopidogrel who
received a combination of aspirin
and clopidogrel within the first 24 h
after hospital admission
Aspirin loading ACS patients without aspirin I I I-B I-B I-A I-A
dose at arrival contraindications who received an
aspirin loading dose of 150–325 mg
within the first 24 h
after hospital admission

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

Appendix 1 (Continued)

Class and level of guideline recommendations

VNHA ACC/AHA ESC

Guideline
recommendation Description NSTEACS STEACS NSTEACS STEACS NSTEACS STEACS

Clopidogrel ACS patients younger than 75 I I I-B I-B I-A I-A

loading dose years of age
without clopidogrel contraindications
who received a clopidogrel loading
dose of 300–600 mg within
the first 24 h
after hospital admission
Beta blocker ACS patients without beta blocker I I I-B I-B I-A I-A
at arrival contraindications who received a beta
blocker within the first 24 h
after hospital admission
ACEI/ARB ACS patients with evidence of I I I-A I-A NA NA
at arrival heart failure, LVSD, diabetes or
hypertension; and without ACEI/ARB
contraindications who received an
ACEI/ARB within the first 24 h
after hospital admission
Statin at arrival ACS without statin contraindications I NA NA NA I-B I-A
who received a statin within the
first 24 h after hospital admission.
At discharge
Aspirin at ACS patients without aspirin I I I-A I-A I-A I-A
discharge contraindications who
were prescribed aspirin
at hospital discharge.
Dual antiplatelet ACS patients without I I I-B I-B I-A I-A
therapy at contraindications of aspirin
discharge and clopidogrel who were
prescribed a combination of aspirin
and clopidogrel at hospital discharge
Beta blocker ACS patients without beta blocker I I I-B I-B I-A I-A
at discharge contraindications who were prescribed
a beta blocker at hospital discharge
ACEI/ARB ACS patients with evidence I I I-A IIa-A I-A IIa-A
at discharge of heart failure,
LVSD, diabetes or hypertension;
and without
ACEI/ARB contraindications who
were prescribed an ACEI/ARB
at hospital discharge
Statin at discharge ACS patients without statin I I I-A I-B I-B I-A
contraindications who were
prescribed a statin at hospital discharge

* References [3–7, 20].

I, class I of recommendation; I-A, class I of recommendation and level A of evidence; I-B, class I of recommendation
and level B of evidence; IIa-A, class IIa of recommendation and level A of evidence; NA, not available.
ACC/AHA, American College of Cardiology Foundation/American Heart Association; ACEI/ARB, angiotensin-convert-
ing enzyme inhibitor or angiotensin II receptor blocker; ACS, acute coronary syndrome; ECS, European Society of Car-
diology; LVSD, left ventricular systolic dysfunction; NSTEACS, non-ST elevation acute coronary syndrome; STEMI, ST
elevation acute coronary syndrome; VNHA, Vietnam National Heart Association.

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T. Nguyen et al. Prescribing for acute coronary syndrome in Vietnam

Appendix 2 Contraindications of guideline-recommended medications*

Medication Contraindication

Aspirin Patients with (i) active bleeding (such as intracranial haemorrhage or GI bleeding); (ii) bleeding disorders;
(iii) active GI ulcer; (iv) aspirin allergy; (v) asthma; or (vi) third trimester pregnancy
Clopidogrel Patients with (i) active bleeding; (ii) clopidogrel allergy; or (iii) planning to have a CABG within 5 days
BB Patients with (i) signs of heart failure; (ii) evidence of a low output state; (iii) increased risk for
cardiogenic shock; (iv) second- or third-degree heart block; (v) asthma/COPD; or (vi) beta blocker allergy
ACEI/ARB Patients with (i) history of angioedema due to ACEI/ARB, heredity or idiopathy;
(ii) SBP <100 mmHg; (iii) bilateral renal artery stenosis; (iv) aortic valve stenosis; (v) pregnancy;
(vi) GFR <30 ml/min; or (vii) ACEI/ARB allergy
Statin Patients with (i) active liver disease or unexplained persistent elevations of hepatic
transaminases (at least three times higher than UNL); (ii) statin allergy; (iii) pregnancy; or (iv) lactation

* References [3–7, 20, 23–25].

ACEI/ARB, angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker; GI, gastrointestinal; CABG, cor-
onary artery bypass grafting; GFR, glomerular filtration rate; SBP, systolic blood pressure; UNL, upper normal limit.

Corresponding Author Katja Taxis, Department of Pharmacy, Unit of Pharmacotherapy and Pharmaceutical Care, University of
Groningen, Antonius Deusinglaan 1, Groningen 9713AV, The Netherlands. Tel.: +31 50 3638205; Fax: +31 50 3632772;
E-mail: k.taxis@rug.nl

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