An accurate record of all medicines taken, including prescribed and non-prescribed, over-the-counter and complementary medicines, is fundamental to a medication assessment and an essential basis for subsequent decision-making.

The Australian Commission on Safety and Quality in Healthcare has a number of resources to support medication history and review.

Interviewing patients at home helps identify issues such as expired, duplicated or medicines that have previously been stopped, as well as the storage conditions of medicines (e.g., GTN tablets). Over-the-counter complementary medications may also be more readily available for review in the home setting.

Medication lists (e.g., hospital admission medication history, inpatient medication chart, discharge medications, patients' medicines list, general practitioner (GP) record of medicines) should be reconciled at the relevant time points.

• Encourage patients or carers to bring all their medicines or a list of medicines to the assessment
• Contact the patient’s GP or local pharmacy if unsure about an accurate medication history, particularly where discrepancies are noted

Non-prescribed medicines should also be recorded.

For example, over-the-counter (OTC) NSAIDs such as ibuprofen may increase the risk of MIs, reduce the efficacy of aspirin in preventing MIs, and increase the risk of acute renal failure associated with ACE inhibitors and have the potential to exacerbate HF. OTC cough and cold medicines may contain sympathomimetics that can oppose the benefits of beta-blockers, precipitate arrhythmias and elevate BP.

See Cautions and monitoring for more information.

Herbal and complementary supplements should also be recorded as they may have particular relevance for people with cardiac disease.

Examples of herbal or complementary supplements with potential interactions or relevance for patients with ACS include:

• Fish oil and krill oil potentially increase bleeding with antithrombotics
• Liquorice potentially causes hypertension, and in regular high doses, may also cause hypokalemia
• Ginkgo may cause hypotension, which may add to the hypotensive effects of ACE inhibitors, ARBs or beta-blockers
• St John’s Wort interacts with many medicines
• Warfarin interacts with numerous herbal and complementary supplements
• Ginger, garlic, ginseng and ginkgo may increase bleeding risk and should not be used during dual anti platelet therapy (DAPT)

Of particular concern is that complementary medicines bought online from some countries may not have undergone the same rigorous quality assurance, and thus may contain different or additional ingredients to those listed on the packaging.

Obtaining an accurate and comprehensive medication history and information about medication risk is important to inform decision-making and the plan for ongoing care.

Specifically ask the patient about:

• Drug allergies or intolerances
• Prescription medicines
• Sleeping tablets
• Inhalers, puffers, sprays, sublingual tablets
• Oral contraceptives, hormone replacement therapy
• OTC medicines
• Analgesics and anti-inflammatory drugs
• Gastrointestinal drugs (i.e., for reflux, heartburn, constipation, diarrhoea)
• Complementary medicines (e.g., vitamins, herbal or natural therapies)
• Topical medicines (e.g., creams, ointments, lotions, patches)
• Inserted medicines (e.g,. nose/ear/eye drops, pessaries, suppositories)
• Injected medicines
• Recently completed courses of medicine
• Other people’s medicine (e.g., family members in the same household)
• Social and recreational drugs
• Intermittent medicines (e.g., weekly or twice a week)
• Nicotine/tobacco use

Elements of medication review

Medication reviews are most often undertaken by doctors, pharmacists and nurses, and may occur during outpatient clinics, home visits, exercise rehabilitation programs, or via the telephone. GPs are often central in coordinating medication management.

The process involves ensuring patients receive the most appropriate treatments for their condition at a safe and appropriate dose, while minimising the risks associated with medication use. The review should also aim to improve patient and carer understanding about their medicines to facilitate informed, shared decision-making regarding treatment.

Once a medication history has been taken and medication lists reconciled, the following elements should be identified:

• Any drug allergies or intolerances
• The suitability of each medicine, using available evidence to guide treatment choice and dose
• The need for additional therapy for untreated conditions
• Potential unwarranted therapy: e.g., medication where there is no current medical indication, or with an unnecessary duration of treatment
• Medicines that may be contraindicated or require precautions (for reasons such as renal or hepatic impairment) or that should be avoided
• Tests required for therapeutic efficacy or to detect adverse effects and toxicity
• Duplication of medicines (e.g,. multiple brands of the same medicine)
• The patient’s understanding of the medicines
• Safe storage and disposal of medicines
• Patient adherence with medications, including assessing the need for dose administration aids
• Non-pharmacological management and lifestyle factors
• Potential impact of Cardiac medications on exercise
• Vaccination status for influenza and pneumococcus
• Need for medical alert bracelet for e.g., anticoagulants or allergies

Engagement of the patient may be aided by explaining the purpose, process and possible outcomes of the review prior to the consultation, asking the patient to bring their medicines (or a list of their medicines) and encouraging the patient to ask questions and actively involve themselves in the discussion.

A medication review process should give the patient an opportunity to raise any concerns and ask questions about their medications. Given the large number of generic medicines for CVD, dedicate some time to discuss potential confusion over brands. Many countries provide a funded medication review service.

The extent and frequency of a medication review should be guided by the individual patient needs. Where resources do not allow for regular medication review of all patients, prioritise high risk patients. Consideration should be given to all factors that may put a patient at risk of hospitalisation or adverse event. The Australian Pharmaceutical Advisory Council suggests the following patient criteria predisposed to medication-related problems:[#australian-pharmaceutical-advisory-council-apac.-2006]

• Currently taking 5 or more regular medications
• Taking more than 12 doses of medication per day
• Significant medication changes in the last 3 months
• Medication with a narrow therapeutic index or requiring therapeutic monitoring
• Symptoms suggestive of an adverse drug reaction (ADR)
• Sub-therapeutic response to treatment
• Suspected non-compliance or inability to manage medication-related therapeutic devices
• Difficulty managing medicines because of literacy or language difficulties, dexterity problems, impaired sight or cognitive difficulties (confusion, dementia)
• Attending a number of different doctors, both GPs and specialists