PRESCRIBING SUPPORT TEAM AUDIT: ACE Inhibitors in the treatment of stable angina (October 2007) PRESCRIBING SUPPORT TECHNICIAN:

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1 PRESCRIBING SUPPORT TEAM AUDIT: ACE Inhibitors in the treatment of stable angina (October 2007) DATE OF AUTHORISATION: AUTHORISING GP: PRESCRIBING SUPPORT TECHNICIAN: SUMMARY SIGN Guideline No. 96 Management of stable angina 1, states that all patients with stable angina would benefit from taking an ACE Inhibitor. This audit has been designed to review all patients on the practice list who have a diagnosis of stable angina so that they may be considered for treatment with an ACE Inhibitor if they are not already taking one. OBJECTIVE To highlight to the practice those patients with stable angina who are not already on an ACE Inhibitor so that the management of their condition may be reviewed in line with the advice in SIGN 96 on the use of ACE Inhibitors in the management of stable angina. RATIONALE SIGN Guideline number 96, Management of stable angina 1, was published in February One of the recommendations in this guideline is that all patients with stable angina should be considered for treatment with an ACE Inhibitor. The evidence base cited for this recommendation are the HOPE 2, EUROPA 3, PEACE 4 and QUIET 5 studies. The results of these 4 large RCTs are conflicting, however two meta-analyses of these and other studies appear to show that ACE Inhibitors significantly reduce all cause and cardiovascular mortality 6,7. SIGN 96 concludes that all patients with stable vascular disease are likely to derive some benefit from taking an ACE Inhibitor, to a degree that is proportional to the level of baseline risk.

2 METHOD A computer search to identify patients with a diagnosis of angina will be carried out. The auditor will record on the data collection form, the following information regarding each patient identified by the search who is not receiving treatment with an ACE Inhibitor; Patient name, Date of birth, whether they have previously been on an ACE Inhibitor, reason for stopping any previous treatment with an ACE Inhibitor. ACE Inhibitor doses require to be titrated gradually and the first dose should be taken at bed time. Patients also require to have U & Es checked after 4 weeks. Given all these counselling points, patients will require to come into the surgery to have treatment commenced. It should be agreed beforehand with the authorising GP whether patients should come to see a GP, practice nurse or prescribing support pharmacist. It should also be agreed beforehand with the practice as to what ACE Inhibitor will be used. Current NHS D&G Joint Formulary options are lisinopril, enalapril and ramipril. Upon receiving the data collection sheet the authorising GP will indicate whether he/she wants each patient to commence treatment with an ACE Inhibitor or whether he/she is happy for treatment to continue unchanged. Where information is not available in the patient s electronic records, the paper notes will be checked by the Prescribing Support Technician and missing information recorded on the data collection form. This information will be verified by the GP and added to the electronic notes by administrative staff. For those patients who are to commence ACE Inihibitor therapy a letter will be sent out to them inviting them into the surgery to see either a GP, Practice Nurse or prescribing support pharmacist, as agreed beforehand with the authorising GP. Some patients may choose to decline treatment and a note should be made in their record stating that this has happened. The local community pharmacy/pharmacies will be informed about the activity. EXCLUSION CRITERIA

3 Patients who have previously been unable to tolerate ACE Inhibitor therapy. Patients who have a contraindication to ACE Inhibitor therapy as listed in the BNF. Any other exclusion criteria as specified by the practice SUGGESTED CRITERIA FOR REFERRAL TO PRACTICE Any criteria specified by the practice. CHANGES TO REPEAT PRESCRIBING 1. The audit must be checked and agreed with a GP in the practice prior to work being undertaken by the Prescribing Support Technician 2. Agreement is made between the Practice and the Prescribing Support Technician on a suitable date for implementation. 3. It is recommended that the prescribing support technician / LHP Pharmacist notify local community pharmacies of any impending changes in prescribing. 4. The Prescribing Support Technician conducts a search of the Practice Clinical System to identify patients with a diagnosis of stable angina and who are not on an ACE Inhibitor as authorised on the Prescribing Review form. 5. Patients are assessed, with respect to potential referral to GP or who require documentation of clinical information held on paper notes only. 6. No patient may be changed beyond the scope of the SPC unless authorised by the prescriber. 7. All changes to prescribing must be recorded within the prescribing field and, wherever possible, an indication recorded for the medication added. 8. Each patient should be informed of any changes made in accordance with the Practice s preferred mode of communication. In this case, the Prescribing Support Team recommends patients be invited into the surgery for initiation of ACE Inhibitor therapy. 9. If the patient is in residential care or has their medication otherwise supervised, e.g. Dosette dispensing, information regarding any changes should also be communicated to the relevant service providers.

4 10. The Prescribing Support technician will communicate information about the review to relevant personnel within the practice e.g. receptionists, nurses and will, if appropriate, create on-screen reminders on the Clinical System. 11. A project file is retained by the Practice containing a list of patients involved, patient letter templates and any individual information sent, a copy of the protocol and prescribing review form and contact details for the Prescribing Support Team. 12. The Prescribing Support Technician may record statistics of the review for report purposes and analysis of the review. No information regarding individual patients leaves the practice. 13. A follow-up audit will take place within 6 months.

5 REFERENCES 1. Scottish Intercollegiate Guidelines Network. Management of stable angina. Edinburgh: SIGN; (SIGN Guideline No.96) 2. Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme-inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med.2000;342 (3): Fox KM. Efficacy of perindopril in reduction of cardiovascular events among people with stable coronary artery disease: randomised, double-blind, placebo-controlled, multicentre trial (the EUROPA study). Lancet. 2003;362(9386): Braunwald E, Domanski MJ, Fowler SE, Geller NL, Bersh BJ, Hsia J, et al. Angiotensin-converting-enzyme inhibition in stable coronary artery disease. N Engl J Med. 2004;351(20): Pitt B, O Neill B, Feldman R, Ferrari R, Schwartz L, Mudra H, et al. The QUinapril Ischaemic Event Trial (QUIET): evaluation of chronic ACE Inhibitor therapy in patients with ischaemic heart disease and preserved left ventricular function. Am J Cardiol. 2001;87(9): Al-Mallah MH, Tleyjeh IM, Abdel-Latif AA, Weaver WD. Angiotensinconverting enzyme inhibitors in coronary artery disease and preserved left ventricular systolic function: a systematic review and meta-analysis of randomised controlled trial. J Am Coll Cardiol. 2006;47(8): Dagenais GR, Pogue J, Fox K, Simoons ML, Yusuf S. Angiotensinconverting enzyme inhibitors in stable vascular disease without left ventricular systolic dysfunction or heart failure: a combined analysis of three trials. Lancet. 2006; 368(9535):

6 ACE Inhibitor in stable angina Data Collection Sheet. Date: Practice: Technician/Pharmacist: Name Date of birth Previous ACE Inhibitor treatment? (Y/N) Reasons for discontinuing any previous ACE Inhibitor treatment THIS COLUMN TO BE COMPLETED BY AUTHORISING GP: ACE Inhibitor therapy to be commenced? (Y/N)