OUTCOMES AND FACTORS ASSOCIATED WITH DISCHARGE AGAINST MEDICAL ADVICE IN PATIENTS DIAGNOSED WITH ACUTE CORONARY SYNDROME IN A SOUTH ASIAN COUNTRY

Abstract

Objectives: Discharge/Left Against Medical Advice (AMA) is associated with worse outcomes in terms of MACE. There are no descriptions of ACS patients who left AMA in our nation cohorts. The aims of this study is to determine MACE in patients signing DAMA/LAMA and quantifying factors associated with LAMA in ACS patients in our population.

Methodology: An Ambi directional cohort study conducted on a total of n=257 patients from Jan 2014 to Dec 2018 who left AMA from a tertiary care hospital. Background data was collected from hospital electronic database and then patients/attendants were contacted through telephonic calls and email for follow up. Primary and secondary end points were to determine MACE and quantify factors associated with discharge AMA respectively.

Results: A total of n=346 patients signed discharge AMA from Jan 2014 to Dec 2018 out of which n=257 were successfully contacted and shared data after informed verbal consents. Out of 257, 63%(n=163) were men and 36.57%(n=94) were female. Hypertension was the common risk factor in both genders 80%(n=205) followed by DM and family history of premature coronary artery disease. Most common mode of presentation was NSTEMI followed by unstable angina and STEMI. Most common reason of LAMA was financial constraints in 43.1%(n=111) followed by treatment preferences in another setup and code DNR (don’t resuscitate). 22.57% patients belonged to low socioeconomic status. Total mortality till date of follow up was 60.7% (n=156) with One-year mortality of 78.8% (n=123) and 1st week mortality after LAMA was 15.18% (n=39). About 35.40% (n=91) of patient left to home and had mortality of 41%(n=64) and 64.56% (n=166) left for another hospital and had mortality of 58.97% (n=92). Those who survived had prevalence of recurrent MI and heart failure of 76% and 49% respectively on follow up.

Conclusion: Discharge against medical advice in ACS patients is associated with higher mortality. We need to educate our patients/attendant regarding disease severity, need of timely interventions and prognosis to decrease frequency of discharge AMA and minimize mortality.