Low Prevalence of Regional Collaborative Clinical Pathways for Acute Coronary Syndromes Is an Issue in Japan
Article ID: CJ-25-0080
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Article ID: CJ-25-0080
Optimal secondary prevention strategies are required for patients with acute coronary syndrome (ACS), whereas post-revascularization care is often less formalized. A significant number of patients are reported to have suboptimal risk factor management during their highest risk period,1 and in Japan the EXPLORE-J registry2 revealed that lipid management in post-ACS patients is suboptimal, resulting in an unfavorable cardiovascular event rate in current clinical practice. A limited number of patients achieve low-density lipoprotein cholesterol (LDL-C) levels <70 mg/dL. In Western countries, approximately 20–30% of patients with ACS discontinued their statin treatment within 4 years.3 The most prevalent reasons for a first discontinuation are avoidable; for example, a nurse-led telephone-based intervention reportedly improved the rate of adherence to statin treatment, and it has also been reported that implementing clinical pathways may help improve adherence to statin use and reduce LDL-C levels after discharge of ACS patients.4,5
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In the Figure optimal medical therapy and treatment targets according to ACS guidelines are presented.6,7 Secondary prevention after ACS is central to increasing quality of life and decreasing morbidity and mortality. A multidisciplinary care system with a regional framework is desirable because lifestyle improvement and modification are the most important goals. Although close and collaborative interaction between the cardiovascular physician or medical team in a specialized hospital and the local primary care system is critical, descriptions of clinical pathways are few in Japanese guidelines.8 Recently, it was reported that implementation of a region-wide clinical pathway for LDL-C management in ACS patients in Japan significantly improved the rate of intensive lipid-lowering therapy and the achievement of LDL-C targets.9 With the introduction of a clinical pathway, the rate of patients achieving LDL-C <70 mg/dL at discharge improved significantly from 37.2% to 54.6%.
Long-term management after acute coronary syndrome based on guidelines from the European Society of Cardiology and the Japan Atherosclerosis Society. ACS, acute coronary syndrome; BP, blood pressure; HbA1c, glycosylated hemoglobin; LDL-C, low-density lipoprotein cholesterol. Modified with permission from references Byrne RA, et al.6 and Okamura T, et al.7
In this issue of the Journal, Minami et al.10 investigate the prevalence and functionality of regional collaborative clinical pathways for ACS in Japan. They used 2 types of surveys: questioner-based survey and web-based survey. The questioner-based survey targeted the prefectural managers of all 47 Japanese Circulation Association branches. The web-based survey supplemented the questioner-based survey by investigating regional collaborative clinical pathways online. Minami et al. report that a total of 45 regional collaborative pathways were identified, of which 18 (11 prefecture-wide and 7 regional-wide) were enrolled, excluding 16 institutional pathways and 11 inactive pathways. Among the prefecture-wide pathways, 10 were managed by prefecture-wide organizations, with 6 recently incorporating an updated protocol sheet for managing lipid-lowering drugs. However, 3 pathways had not been updated in over 10 years. Among the region-wide pathways, 4 were managed by regional medical associations, and 4 pathways had not been updated in 10 years.
The authors also show that most pathways include target levels for risk factors such as LDL-C, HbA1c, and blood pressure. Notably, only 8 pathways described the current recommended LDL-C level of <70 mg/dL. Further, half of the pathways were judged as non-functioning based on the questioner-based surveys. All of the functioning pathways were prefectural-wide and recently updated.
The authors suggest that a potential reason for the limited penetration of regional collaborative pathways may be difficulty in establishing the pathways. Therefore, it is expected that future ACS pathways will be developed by government or academia and will include details on the implementation of treatment protocols and updating of target levels. The authors also note that the ideal pathways should be characterized as prefecture-wide, incorporating specific treatment protocols, and having updated target risk factors and recommended medications. The authors also suggest that unified pathways established by academic societies should be adapted to fit the specific characteristics of each region. The rural–urban disparity in prognosis for ACS patients is a significant issue worldwide.11 A Canadian study reported that mortality rates were 13% higher in rural remote areas compared with urban settings.12 Another issue is the uneven distribution of physicians in each region in Japan. By introducing regional collaborative clinical pathways, it will be necessary for each region to coordinate with administrative organizations and medical associations according to their specific characteristics and requirements.
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None declared.
