ASSESSMENT AND IMPROVEMENT OF COMPLIANCE WITH GUIDELINE-RECOMMENDED SECONDARY PREVENTION THERAPY AFTER MYOCARDIAL INFARCTION: A QUALITY IMPROVEMENT PROJECT IN A PUBLIC SECTOR HOSPITAL IN PAKISTAN

Abstract

Background Effective secondary prevention following myocardial infarction (MI) plays a crucial role in reducing recurrent cardiovascular events, rehospitalization, and mortality. Despite established international guideline recommendations, compliance with discharge-based secondary prevention measures remains variable in many resource-limited public-sector healthcare settings. This Quality Improvement Project (QIP) was conducted to assess and improve compliance with guideline-recommended secondary prevention therapy among post-MI patients discharged from the cardiology ward of Ayub Teaching Hospital, Abbottabad. Objective To assess baseline compliance with guideline-recommended secondary prevention measures after MI and evaluate the impact of targeted quality improvement interventions on discharge practices in a tertiary care public-sector hospital. Methodology This clinical audit-based Quality Improvement Project was conducted in the cardiology ward of Ayub Teaching Hospital, Abbottabad. Adult patients admitted with STEMI or NSTEMI and discharged alive from the cardiology ward were included using non-probability consecutive sampling. Baseline audit data were collected from patients discharged between 15 August 2025 and 15 October 2025, while the post-intervention re-audit was conducted between 1 November 2025 and 30 December 2025. Compliance with pharmacological and non-pharmacological components of the secondary prevention discharge bundle was assessed using a structured audit proforma based on international guideline recommendations. Interventions included introduction of a standardized post-MI discharge checklist, sensitization sessions for residents and house officers, reinforcement of documentation practices, and reminder posters regarding discharge bundle components. Results A total of 86 patients were included in the baseline audit cycle and 82 patients in the post-intervention cycle. Baseline assessment demonstrated variable compliance with secondary prevention measures. Aspirin was prescribed in 84/86 (97.7%) patients, P2Y12 inhibitors in 79/86 (91.9%), high-intensity statins in 76/86 (88.4%), beta-blockers in 63/86 (73.3%), and ACE-I/ARB/ARNI therapy in 58/86 (67.4%) eligible patients. Documentation of smoking cessation counselling was present in only 9/28 (32.1%) current smokers, follow-up planning in 47/86 (54.7%) patients, and affordability/adherence counselling in 18/86 (20.9%) patients. Overall complete bundle compliance was observed in 24/86 (27.9%) patients during the baseline audit cycle. Following implementation of targeted interventions, compliance improved across most components of the discharge bundle. Aspirin prescription increased to 82/82 (100%), P2Y12 inhibitor use to 80/82 (97.6%), high-intensity statin therapy to 78/82 (95.1%), beta-blocker prescription to 73/82 (89.0%), and ACE-I/ARB/ARNI therapy to 69/82 (84.1%). Smoking cessation counselling improved to 18/25 (72.0%), follow-up documentation to 72/82 (87.8%), and affordability/adherence counselling to 57/82 (69.5%). Overall complete bundle compliance improved substantially from 27.9% to 71.9% following intervention. Conclusion Significant gaps existed in compliance with guideline-recommended secondary prevention measures among post-MI patients discharged from the cardiology ward at baseline, particularly in counselling and documentation practices. Implementation of simple, low-cost quality improvement interventions resulted in substantial improvement in both pharmacological and non-pharmacological components of post-MI discharge care. Regular audit cycles and structured discharge processes may help improve adherence to evidence-based cardiovascular care in resource-limited healthcare settings in Pakistan