Sixty one patients were referred to the clinic. At clinic discharge (n=59) all but one patient was prescribed an ACEI inhibitor or ARB (one contra-indicated: angio-oedema) and three patients were not prescribed a beta-blocker (bradycardia).
For ACEI /ARB, the target dose was attained in 14 patients (24 per cent) with 24 patients (41 per cent) reaching at least 50 per cent of the maximum dose. For beta-blockers, the target dose was attained in one case (two per cent) with only eight patients (13.5 per cent) reaching at least 50 per cent of the maximum dose.
Two-thirds of patients with an ejection fraction of less than 40 per cent were also prescribed eplerenone. Further analysis of these patients is not available.
The reasons that target doses were not achieved are shown in the diagram to the right. Clinical reasons relating to blood pressure, heart rate (beta-blockers) and renal function were dose limiting factors as well as logistical reasons for patients attending a hospital-based service
A pharmacist prescriber is well placed to offer a post discharge medicines optimisation in this high risk patient group. Titration of hospital discharge doses towards target levels is possible but clinical and logistical reasons often mean that target doses cannot be attained. Further evaluation of the appropriateness of eplerenone prescribing is required.
In addition, further research will explore the options regarding pharmacist-led medicines optimisation for all patients post discharge following STEMI and the preferred model of care.