2 15 Prevalence of secondary prevention medication use in South America INTRODUCTION Coronary heart disease (CHD) is the main cause of death and one of the most important causes of disability worldwide and in South America (1). Cardioprotective medications, including antiplatelet, anti-hypertensive, lipid-lowering and hypoglycaemic medication, are effective in preventing CHD morbidity and mortality (2–4) and their long-term use in patients with established CHD is recommended by international guidelines (5). Despite guidelines for secondary prevention of CHD recommending the use of antiplatelets, statins, beta-blockers and angiotensin-converting-enzyme inhibitors (2), research shows that the use of these medications in CHD patients is suboptimal (3,6,7). This gap between guideline recommendations and clinical use has been described in high-income countries (4,8–11), but information from middle-and and low income countries, including the South American region (12), is limited. Meta-analyses have been conducted to explore this problem in North America, Europe (9) and China (13), and there is high variability by region (14) in the use of guideline-recommended medications for secondary prevention. To date, an overview and general picture of secondary prevention medication and its determinants in South America is lacking. Therefore, the aim of this systematic review is to summarize evidence on the prevalence of cardioprotective medication use for secondary prevention of CHD in South America. The secondary aims of this work are to summarize the findings on guideline compliance, examine time trends and identify potential factors associated with use of medication in patients with established CHD. METHODS Search strategy This review was registered with PROSPERO (registration number CRD42020206657) and conducted in accordance with the PRISMA guidelines (15) (Supplementary File 1). We conducted a systematic search on April 28th, 2021 on the following databases: PubMed, Embase, Cochrane, LILACS and SciELO. The search strategy contained information on the CHD diagnosis of the patients, the country where the study was performed and the most common classes of cardioprotective medications in the outpatient clinic setting. Studies published between 2000 and 2020 in English, Spanish or Portuguese and conducted in South America (Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Paraguay, Peru, Suriname, Uruguay, Venezuela, and Guyana) reporting the prevalence of cardioprotective medications in CHD patients were included. Broad terms were included for the diagnosis of CHD: ‘coronary artery disease’, ‘myocardial infarction’, ‘ST-elevation myocardial infarction’, ‘non-ST-elevation myocardial infarction’, ‘acute coronary syndrome’, ‘angina pectoris’, ‘acute coronary syndrome’, ‘coronary atherosclerosis’, interventions such as ‘coronary artery bypass graft’ and ‘percutaneous coronary intervention’, and commonly used acronyms for these terms. For details on the search strategy and PROSPERO registration see Supplementary File 2. Eligibility criteria
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