Quality improvement measures ameliorate ACS outcomes

While multiple randomised controlled trials have outlined the optimal care for patients with acute coronary syndromes (ACS), evidence-based therapies are not always applied, particularly in low- and middle-income countries.  In this Brazilian study, the authors hypothesised that a multifaceted quality improvement (QI) intervention could improve the use of evidence-based therapies and improve ACS outcomes.

BRIDGE-ACS (Brazilian Intervention to Increase Evidence Usage in Acute Coronary Syndromes) was a cluster-randomised trial that enrolled a total of 1150 ACS patients between March and and November 2011.  The multifaceted QI intervention used included reminders, a checklist, case management, and educational materials; clusters were randomly allocated to the use of these or to a routine strategy.  The main outcome measure was the percentage of all eligible patients who received all evidence-base therapies during the first 24 hours of treatment, where no contraindications were present.

40% of patients presented with ST-elevation myocardial infarction (STEMI), 35.6% with non-ST-segment myocardial infarction, and 23.6% with unstable angina.  Almost 80% of the hospitals included were from major urban areas, and 41.2% had 24-hour PCI facilities available.  In the intervention group, 67.9% of all eligible patients received all the appropriate acute therapies, compared to 49.5% in the control group.  This also translated into an increased likelihood of receiving appropriate discharge medications (51.0% vs. 31.9%).  In-hospital cardiovascular event rates were 5.5% in the intervention group vs 7.0% in the control group, and 30-day all-cause mortality was also reduced (7.0% vs 8.4%).


A multifaceted educational intervention in Brazil led to a significant improvement in the use of evidence-based therapies, suggesting that this approach may improve outcomes following ACS for patients in low- and middle-income countries.

  • Berwanger O, Guimaraes HP, Laranjeira LN et al.  Effect of a Multifaceted Intervention of Use of Evidence-Based Therapies in Patients With Acute Coronary Syndromes in Brazil.  The BRIDGE-ACS Randomized trial.  JAMA 2012;307:2041-2049

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