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Acute coronary syndrome

Map of Medicine suggests interventions that improve productivity while maintaining quality and safety


  • Ensure fondaparinux is offered to patients with unstable angina or non ST-segment elevation myocardial infarction (NSTEMI).1 Fondaparinux has been shown to be clinically superior to enoxaparin in reducing bleeding risk and mortality in patients with unstable angina and NSTEMI.1 Health economic analyses have also shown fondaparinux to be superior to enoxaparin as it requires only once-daily administration with no weight adjustments, while enoxaparin is weight dependent and administered twice daily. Fondaparinux has been associated with a daily cost saving of £3.97 per person and a mean quality-adjusted life year (QALY) increase of 0.04 when compared with enoxaparin.2


  • Consider prasugrel, in combination with aspirin, as first-line treatment only in eligible patients with acute coronary syndrome having percutaneous coronary intervention (PCI).3 Prasugrel, along with aspirin, should be first-line treatment in patients having PCI only when the patient has diabetes, a stent thrombosis while on clopidogrel therapy or when immediate PCI for ST-segment elevation myocardial infarction (STEMI) is necessary.3 Prasugrel has been found to be a clinically and cost-effective option in only these groups of patients when compared with clopidogrel.3


  • Ensure coronary angiography +/- PCI is offered within 96 hours of admission to individuals with unstable angina or NSTEMI at intermediate to high risk of adverse cardiovascular events.1 Coronary angiography (with follow-on PCI if indicated) should be offered within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted six-month mortality above 3%) and no contraindications to angiography such as active bleeding or comorbidity.1 This strategy for patients with unstable angina or NSTEMI is recommended when PCI can be offered at the same time as angiography and within the recommended time scale. It has been shown to significantly reduce the risk of death and non-fatal MI, both in the short term (six to 12 months) and longer term (greater than two years).1 This early intervention strategy is associated with a higher mean cost at £5,654 per patient compared with a conservative strategy at £1,778 per patient. However, mean costs during the first year after the index hospitalisation were lower with early intervention (£1,106 per patient) when compared with a conservative treatment strategy (£2,735 per patient). The mean incremental cost per QALY gained by early intervention was approximately £55,000 for low-risk, £22,000 for medium-risk and £12,000 for high-risk patients.4,5


  • Ensure all patients post MI are offered entry into a cardiac rehabilitation programme.7 Cardiac rehabilitation in patients post MI reduces all-cause and cardiovascular mortality rates.6 Cardiac rehabilitation programmes should be tailored to patient needs, with measures put in place to support uptake and adherence.6 A UK-based costing study reported the cost of a comprehensive cardiac rehabilitation programme to be £207 per patient. The estimated incremental cost-effectiveness ratio was £7,860 for men and £8,360 for women per QALY gained.7

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    This document is not to be substituted for a healthcare professional's diagnosis. © 2011 Map of Medicine Ltd Acute coronary syndrome 2/2


    The productivity considerations presented in this document are relevant to the UK. They were identified by systematically searching for and appraising productivity evidence from multiple sources, including NICE guidance, health economic databases and Zynx Health (a sister company of Map of Medicine). A productivity message explicitly states interventions that can reduce the cost of care, whilst maintaining or improving patient outcomes. Actions that are believed to lead to improved productivity, but lack unequivocal clinical or economic evidence, are not included. Some productivity considerations are informed by more recent evidence than that included in relevant national guidelines. The document has been peer reviewed by an independent group of experts.


    1. National Clinical Guideline Centre for Acute Chronic Conditions (NCGC-ACC). Unstable Angina and NSTEMI: the early management of unstable angina and non-ST-segment-elevation myocardial infarction. London: NCGC-ACC; 2010.

    2. Sculpher M, Lozano-Ortega G, Sambrook J et al. Fondaparinux versus Enoxaparin in non-ST-elevation acute coronary syndromes: short-term cost and long term cost-effectiveness using data from the Fifth Organization to Assess Strategies in Acute Ischemic Syndromes Investigators (OASIS-5) trial. Am Heart J 2009; 157: 845-52.

    3. National Institute for Clinical Excellence (NICE). Prasugrel for the treatment of acute coronary syndromes with percutaneous coronary intervention. Technology Appraisal Guidance 182. London: NICE; 2010.

    4. Hoenig M, Aroney C, Scott I et al. Early invasive versus conservative strategies for unstable angina & non-ST-elevation myocardial infarction in the stent era. Cochrane Database Syst Rev 2010; CD004815.

    5. Henriksson M, Epstein D, Palmer Set al. The cost-effectiveness of an early interventional strategy in non-ST-elevation acute coronary syndrome based on the RITA 3 trial - technical report. Heart 2008; 94: 717-23.

    6. National Collaborating Centre for Primary Care (NCC-PC). Post myocardial infarction: Secondary prevention in primary and secondary care for patients following a myocardial infarction. London: Royal College of General Practitioners (RCGP); 2007.

    7. Taylor R, Kirby B. Cost implications of cardiac rehabilitation in older patients. Coron Artery Dis 1999; 10: 53-6.

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