Contemporary Trends of Optimal Evidence-Based Medical Therapy at Discharge for Patients Surviving Acute Myocardial Infarction From the Korea Acute Myocardial Infarction Registry

Optimal medical therapy, clinical outcome and its predictors in patients with acute coronary syndrome after discharge with secondary prevention medications at University of Gondar Comprehensive Specialized Hospital, North West Ethiopia, 2023: A retrospective follow-up study

BACKGROUND

The life-threatening diseases known as ACS (acute coronary syndrome) continue to produce considerable rates of morbidity and mortality despite breakthroughs in therapy. The study determined clinical outcome and its predictors in patients at the University of Gondar Comprehensive and Specialized Hospital (UOGCSH), North West Ethiopia.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study design was employed at UOGCSH from January 31, 2018 to February 1, 2023. The hospital used a systematic random sampling procedure to select study participants from the medical records of patients in chronic cardiac follow-up clinics.

MAIN OUTCOME MEASURES

Exposures were optimal medical therapy (OMT) versus non-optimal medical therapy collected from May to August 2023. Descriptive and analytical statistics were employed to compare study groups. A binary logistic regression model was employed to identify candidate variables for further analysis. Cox's proportional hazard model and log-rank test were employed, with a P-value < 0.05 used to evaluate statistical significance. A five-year all-cause mortality after discharge estimate was displayed by using Kaplan-Meier curves.

RESULTS

Among 422 patients with ACS [mean age, 61.56 (SD = 9.686) years; 54.7% male], of whom only 59.2% (250) received optimal medical therapy at discharge. Age ≥ 65, atrial fibrillation, chronic kidney diseases, and cardiogenic shock were negative independent predictors of optimal medical therapy. On the other hand, male sex was independently associated with the use of optimal medical therapy. All-cause mortality occurred in 16.6% (n = 70) and major adverse cardiac events occurred in 30.8% (n = 130) of patients with a 95% CI of 0.132-0.205 and 0.264-0.355, respectively. Multivariate analyses indicated that OMT was significantly associated with reduced all-cause mortality (aHR: 0.431, 95% CI: 0.222-0.835; P = 0.013).

CONCLUSION

This study revealed that the use of preventive OMT in patients discharged with acute coronary syndrome was associated with a reduction in all-cause mortality. However, the use of this OMT is suboptimal.

Evidence-Based Optimal Medical Therapy and Mortality in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention

Background The secondary prevention with pharmacologic therapy is essential for preventing recurrent cardiovascular events in patients experiencing acute myocardial infarction. Guideline-based optimal medical therapy (OMT) for patients with acute myocardial infarction consists of antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, β-blockers, and statins. We aimed to determine the prescription rate of OMT use at discharge and to evaluate the impact of OMT on long-term clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention in the drug-eluting stent era using nationwide cohort data. Methods and Results Using the National Health Insurance claims data in South Korea, patients with acute myocardial infarction who had undergone percutaneous coronary intervention with a drug-eluting stent between July 2013 and June 2017 were enrolled. A total of 35 972 patients were classified into the OMT and non-OMT groups according to the post-percutaneous coronary intervention discharge medication. The primary end point was all-cause death, and the 2 groups were compared using a propensity-score matching analysis. Fifty-seven percent of patients were prescribed OMT at discharge. During the follow-up period (median, 2.0 years [interquartile range, 1.1-3.2 years]), OMT was associated with a significant reduction in the all-cause mortality (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.76-0.90]; P<0.001) and composite outcome of death or coronary revascularization (aHR, 0.89 [95% CI, 0.85-0.93]; P<0.001). Conclusions OMT was prescribed at suboptimal rates in South Korea. However, our nationwide cohort study showed that OMT has a benefit for long-term clinical outcomes on all-cause mortality and composite outcome of death or coronary revascularization after percutaneous coronary intervention in the drug-eluting stent era.

Risks of Recurrent Cardiovascular Events and Mortality in 1-Year Survivors of Acute Myocardial Infarction Implanted with Newer-Generation Drug-Eluting Stents

Current treatments for acute myocardial infarction (AMI) have dramatically improved clinical outcomes during the first year after AMI. Less is known, however, about the subsequent risks of recurrent cardiovascular events and mortality in patients who survive 1 year after AMI. The purpose of the present study is to evaluate long-term clinical outcomes in 1-year AMI survivors who were implanted with newer-generation drug-eluting stents (DESs) since 2010. The COREA-AMI (CardiOvascular Risk and idEntificAtion of potential high-risk population in AMI) registry consecutively enrolled AMI patients who underwent percutaneous coronary intervention (PCI), and patients who received newer-generation DESs since 2010 were analyzed. The primary endpoint was major adverse cardiovascular events (MACEs), and secondary endpoint was all-cause mortality. Of 6242 AMI patients, 5397 were alive 1 year after the index procedure. The cumulative incidence of MACEs and all-cause death 1 to 7 years after AMI were 28.4% (annually 4–6%) and 20.2% (annually 3–4%), respectively. Multivariate analysis showed that uncontrolled systolic blood pressure (SBP) and serum low-density lipoprotein cholesterol (LDL-C) concentration, as well as traditional risk factors, were associated with MACEs and all-cause death. Recurrent non-fatal myocardial infarction, ischemic stroke, and bleeding events within 1 year were significantly associated with all-cause death. The risks of adverse cardiovascular events and death remain high in AMI patients more than 1 year after the index PCI with newer-generation DESs. Traditional risk factors, uncontrolled SBP and LDL-C, and non-fatal adverse events within 1 year after the index procedure strongly influence long-term clinical outcomes.

Prescription Rates for Antiplatelet Therapy (APT) in Coronary Artery Disease (CAD) - What Benchmark are We Aiming at in Continuing Medical Education (CME)?

Physicians always aim to improve their patients' health. CME should be designed not only to provide knowledge transfer, but also to influence clinical decision-making and to close performance gaps. In aretrospective study we analysed prescription rates for APT in 254,932 CAD patients (male: 64.4%), treated in atotal of 3,405 practices in 2019 in aDMP in the region of North Rhine, Germany. Analyses were run for the whole study population stratified by sex as well as for subgroups of patients suffering from myocardial infarction/acute coronary syndrome, or who have been treated with percutaneous coronary intervention or bypass surgery. Patients mean age was 72.7 ± 11.2 years (mean ± 1SD), mean duration of DMP participation was 7.2 ± 4.7 years, and mean cumulative number of DMP visits was 27 ± 17. APT prescription rates were 85.0% in male and 78.8% in female CAD patients. In subgroups of male CAD patients APT prescription rates were between 89.7% and 92.8%, in the same subgroups of female CAD patients the corresponding rates were between 87.8% and 92.0%. Rates for amissing APT prescription per practice were between .0044% and .0062% for male and female CAD patients, respectively. Rates for amissing APT prescription per practice and DMP visit were .0002% for both sexes. These results suggest that a DMP can achieve high attainment rates for APT in CAD. To further improve attainment rates, consideration of absolute numbers of eligible patients per practice or physician is probably more appropriate than expression of performance as percentage values. This is especially true if attainment rates show substantial variations between subgroups, if subgroups show substantial variation in size, if attainment rates are already in the magnitude of 80% or higher, and if there are disparities in the evidence base underlying treatment recommendations related to subgroups.

Contemporary use of lipid-lowering therapy for secondary prevention in Korean patients with atherosclerotic cardiovascular diseases

BACKGROUND/AIMS

We evaluated the contemporary use of lipid-lowering therapy (LLT) in Korean patients with atherosclerotic cardiovascular disease (ASCVD), and identified factors associated with statin non-prescription.

METHODS

Using the Korean Health Insurance Review and Assessment data, we identified LLT-naïve subjects newly diagnosed with ASCVD between 2011 and 2012, and followed up until 2015. LLT-naïve status was defined as no LLT prescription for 1 year before ASCVD diagnosis. ASCVD was defined as first hospitalization or emergency room visit for coronary artery disease (CAD), acute cerebrovascular disease (CVD), or peripheral artery disease (PAD). Statin intensity was defined per the 2013 American College of Cardiology/American Heart Association guideline for cholesterol treatment.

RESULTS

The study enrolled 80,884 subjects newly diagnosed with ASCVD, of whom only 48,725 (60.2%) received LLT during the follow-up period. Statin, combination of statin and non-statin, and non-statin LLT were administered in 50.5%, 9.7%, and 0.1% of all subjects, respectively. Statins were prescribed to 80.4% of CAD patients but only to 50.2% and 46.8% of CVD and PAD patients. Statin-based LLT usually had moderate- (77.2%) or high-intensity (18.5%). Subjects not prescribed statins were younger or older (< 40 or ≥ 70 years), more commonly female, and more likely to have comorbidities. Statins were prescribed at the time of ASCVD diagnosis in 45.5% of all subjects, and in 53.0% within 90 days of diagnosis.

CONCLUSION

Only 60% of LLT-naïve Korean patients newly diagnosed with ASCVD received statins. Statins were often prescribed in subjects with CAD but less commonly in those with CVD or PAD. Moderate-intensity statins were most frequently used.

Association of beta-blocker treatment with mortality following myocardial infarction in patients with chronic obstructive pulmonary disease and heart failure or left ventricular dysfunction: a propensity matched-cohort analysis from the High-Risk Myocardial Infarction Database Initiative

AIMS

To determine the influence of baseline beta-blocker use on long-term prognosis of myocardial infarction (MI) survivors complicated with heart failure (HF) or with left ventricular dysfunction and with history of chronic obstructive pulmonary disease (COPD).

METHODS AND RESULTS

Among the 28 771 patients from the High-Risk MI Database Initiative we identified 1573 patients with a baseline history of COPD. We evaluated the association between beta-blocker use at baseline (822 with beta-blocker and 751 without) on the rates of all-cause and cardiovascular mortality. On univariable Cox analysis, beta-blocker use was found to be associated with lower rates of both all-cause [hazard ratio (HR) = 0.61, 95% confidence interval (CI) 0.51-0.75, P < 0.0001] and cardiovascular mortality (HR = 0.63, 95% CI 0.51-0.78, P < 0.0001). After extensive adjustment for confounding, including 24 baseline covariates, COPD patients still benefited from beta-blocker usage (HR = 0.73, 95% CI 0.60-0.90, P = 0.002 for all-cause mortality; HR = 0.77, 95% CI 0.61-0.97, P = 0.025 for cardiovascular mortality). Adjusting for propensity scores (PS) constructed from the 24 aforementioned baseline characteristics provided similar results. In a cohort of 561 pairs of patients taking or not taking beta-blocker matched on PS using a 1:1 nearest-neighbour matching method, patients treated with beta-blocker experienced fewer all-cause deaths (HR = 0.71, 95% CI 0.56-0.89, P = 0.003) and cardiovascular deaths (HR = 0.76, 95% CI 0.59-0.97, P = 0.032).

CONCLUSIONS

In the specific setting of a well-treated cohort of high-risk MI survivors, beta-blockers were associated with better outcomes in patients with COPD.