[Evaluation of a public health programme: direct Clopidogrel administration by cardiology units in acute myocardial infarction]. / Valutazione di un intervento di sanità pubblica: somministrazione diretta del trattamento con Clopidogrel nell'infarto miocardico acuto.

OBJECTIVES: to compare the benefit of a personalised outpatient therapy prescribed upon discharge by the cardiology unit to the patients undergoing a percutaneous coronary intervention with drug-eluting stent or bare-metal stent vs. the usual practice. DESIGN: controlled, multicentre, non-randomized study that enrolled patients who underwent coronary stent implantation and treated in the year after stent implantation with two protocols: the treatment group received Clopidogrel directly from the cardiology unit at each monitoring visit; the control group received a prescription for outpatient treatment through the standard retail pharmacy channel. SETTING AND PARTICIPANTS: the recruited centres adopting the new treatment protocol are Magenta, Legnano, and Rho (ASL Milano1, Magenta - Lombardy Region, Northern Italy), with 477 patients included; the recruited centres following for the standard protocol are Niguarda and San Carlo (ASL Milano), with 307 patients included. We identified all patients aged ≥40 years, discharged after coronary stent implantation between January 1st, 2010 and March 31st, 2011, and followed for 1 year. MAIN OUTCOME MEASURES: all coronary events, second coronary interventions or deaths in the year after hospital discharge. RESULTS: we found differences between the two treatments in relation with coronary events: hazard ratio (HR) for the control group in patients with ST-elevation myocardial infarction (STEMI) is 3.32 (95%CI 1.67- 6.62), HR in patients with non-ST elevation myocardial infarction (NSTEMI) is 2.44 (95%CI 1.07-5.57). The compliance at 1 year is 80% in the treated group vs. 70% in the control group, respectively (p-value <0.01). CONCLUSIONS: the application of the therapeutic plan, governed by the interventional cardiology, increases treatment adherence and reduces the risk of cardiovascular events subsequent to the insertion of a stent. It is crucial, therefore, to improve the adherence to dual antiplatelet therapy by using high levels of integration between inpatient and outpatient care to reduce adverse health outcomes during post-surgery phase and to ensure the taking in charge of the patient.