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Mars K, Humphries S, Leissner P, Jonsson M, Karlström P, Lauermann J, Alfredsson J, Kellerth T, Ravn-Fischer A, Erlinge D, Lindahl B, Yndigegn T, Jernberg T, Held C, Olsson EMG, Hofmann R. Effects of beta-blockers on quality of life and well-being in patients with myocardial infarction and preserved left ventricular function-a prespecified substudy from REDUCE-AMI. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024:pvae062. [PMID: 39217445 DOI: 10.1093/ehjcvp/pvae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2024] [Revised: 08/12/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
AIMS In the Randomized Evaluation of Decreased Usage of Beta-Blockers after Acute Myocardial Infarction (REDUCE-AMI) study, long-term beta-blocker use in patients after acute myocardial infarction (AMI) with preserved left ventricular ejection fraction demonstrated no effect on death or cardiovascular outcomes. The aim of this prespecified substudy was to investigate effects of beta-blockers on self-reported quality of life and well-being. METHODS AND RESULTS From this parallel-group, open-label, registry-based randomized clinical trial, EQ-5D, and World Health Organization well-being index-5 (WHO-5) questionnaires were obtained at 6-10 weeks and 11-13 months after AMI in 4080 and 806 patients, respectively. We report results from intention-to-treat and on-treatment analyses for the overall population and relevant subgroups using Wilcoxon rank sum test and adjusted ordinal regression analyses. Of the 4080 individuals reporting EQ-5D (median age 64 years, 22% female), 2023 were randomized to beta-blockers. The main outcome, median EQ-5D index score, was 0.94 [interquartile range (IQR) 0.88, 0.97] in the beta-blocker group, and 0.94 (IQR 0.88, 0.97) in the no-beta-blocker group 6-10 weeks after AMI, OR 1.00 [95% CI 0.89-1.13; P > 0.9]. After 11-13 months, results remained unchanged. Findings were robust in on-treatment analyses and across relevant subgroups. Secondary outcomes, EQ-VAS and WHO-5 index score, confirmed these results. CONCLUSION Among patients after AMI with preserved left ventricular ejection fraction, self-reported quality of life and well-being was not significantly different in individuals randomized to routine long-term beta-blocker therapy as compared to individuals with no beta-blocker use. These results appear consistent regardless of adherence to randomized treatment and across subgroups which emphasizes the need for a careful individual risk-benefit evaluation prior to initiation of beta-blocker treatment.
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Affiliation(s)
- Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sjukhusbacken 10, 188 83, Sweden
| | - Sophia Humphries
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | - Philip Leissner
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | - Martin Jonsson
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sjukhusbacken 10, 188 83, Sweden
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Jönköping 551 85 Sweden
| | - Jörg Lauermann
- Department of Internal Medicine, Ryhov County Hospital, Jönköping 551 85 Sweden
| | - Joakim Alfredsson
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping 581 83, Sweden
| | - Thomas Kellerth
- Division of Cardiology and Emergency medicine, Centralsjukhuset Karlstad, Karlstad 651 82, Sweden
| | - Annica Ravn-Fischer
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg 405 30, Sweden
- Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska Academy University of Gothenburg, Gothenburg 405 30, Sweden
| | - David Erlinge
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund 222 42, Sweden
| | - Bertil Lindahl
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala 751 85, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Troels Yndigegn
- Department of Cardiology, Clinical Sciences, Lund University, Skane University Hospital, Lund 222 42, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm 171 77, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala 751 85, Sweden
- Uppsala Clinical Research Center, Uppsala University, Uppsala 751 85, Sweden
| | - Erik M G Olsson
- Department of Women's and Children's Health, Uppsala University, Uppsala 751 85, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, Stockholm, Sjukhusbacken 10, 188 83, Sweden
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Narendren A, Whitehead N, Burrell LM, Yudi MB, Yeoh J, Jones N, Weinberg L, Miles LF, Lim HS, Clark DJ, Al-Fiadh A, Farouque O, Koshy AN. Management of Acute Coronary Syndromes in Older People: Comprehensive Review and Multidisciplinary Practice-Based Recommendations. J Clin Med 2024; 13:4416. [PMID: 39124683 PMCID: PMC11312870 DOI: 10.3390/jcm13154416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/20/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Managing health care for older adults aged 75 years and older can pose unique challenges stemming from age-related physiological differences and comorbidities, along with elevated risk of delirium, frailty, disability, and polypharmacy. This review is aimed at providing a comprehensive analysis of the management of acute coronary syndromes (ACS) in older patients, a demographic substantially underrepresented in major clinical trials. Because older patients often exhibit atypical ACS symptoms, a nuanced diagnostic and risk stratification approach is necessary. We aim to address diagnostic challenges for older populations and highlight the diminished sensitivity of traditional symptoms with age, and the importance of biomarkers and imaging techniques tailored for older patients. Additionally, we review the efficacy and safety of pharmacological agents for ACS management in older people, emphasizing the need for a personalized and shared decision-making approach to treatment. This review also explores revascularization strategies, considering the implications of invasive procedures in older people, and weighing the potential benefits against the heightened procedural risks, particularly with surgical revascularization techniques. We explore the perioperative management of older patients experiencing myocardial infarction in the setting of noncardiac surgeries, including preoperative risk stratification and postoperative care considerations. Furthermore, we highlight the critical role of a multidisciplinary approach involving cardiologists, geriatricians, general and internal medicine physicians, primary care physicians, and allied health, to ensure a holistic care pathway in this patient cohort.
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Affiliation(s)
- Ahthavan Narendren
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
| | - Natalie Whitehead
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Louise M. Burrell
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Matias B. Yudi
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Julian Yeoh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
| | - Nicholas Jones
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Lachlan F. Miles
- Department of Critical Care, The University of Melbourne, Melbourne, VIC 3010, Australia; (L.W.); (L.F.M.)
- Department of Anaesthesia, Austin Health, Heidelberg, VIC 3084, Australia
| | - Han S. Lim
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Cardiology, Northern Health, Epping, VIC 3076, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - David J. Clark
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Ali Al-Fiadh
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Omar Farouque
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
| | - Anoop N. Koshy
- Department of Cardiology, Austin Health, Heidelberg, VIC 3084, Australia; (A.N.); (N.W.); (L.M.B.); (M.B.Y.); (J.Y.); (N.J.); (H.S.L.); (D.J.C.); (A.A.-F.); (O.F.)
- Department of Medicine, The University of Melbourne, Melbourne, VIC 3052, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Parkville, VIC 3052, Australia
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Blackburn DF, Yao S, Taylor JG, Alefan Q, Lix LM, Eurich DT, Choudhry NK. Measuring the Influence of Side Effect Expectations, Beliefs, and Incident Side Effects on the Risk for Drug Discontinuation Among Individuals Starting New Medications, a Cross-sectional Study. Patient Prefer Adherence 2024; 18:979-989. [PMID: 38774475 PMCID: PMC11107835 DOI: 10.2147/ppa.s451012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 05/04/2024] [Indexed: 05/24/2024] Open
Abstract
Purpose To measure the impact of beliefs, expectations, side effects, and their combined effects on the risk for medication nonpersistence. Patients and methods Using a cross-sectional design, individuals from Saskatchewan, Canada who started a new antihypertensive, cholesterol-lowering, or antihyperglycemic medication were surveyed about risk factors for nonpersistence including: (a) beliefs measured by a composite score of three questions asking about the threat of the condition, importance of the drug, and harm of the drug; (b) incident side effects attributed to treatment; and (c) expectations for side effects before starting treatment. Descriptive statistics and logistic regression models were used to quantify the influence of these risk factors on the outcome of nonpersistence. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated. Results Among 3,029 respondents, 5.8% (n=177) reported nonpersistence within four months after starting the new drug. After adjustment for numerous covariates representing sociodemographics, health-care providers, medication experiences and beliefs, both negative beliefs (OR: 7.26, 95%CI: 4.98-10.59) and incident side effects (OR: 8.00, 95%CI: 5.49-11.68) were associated with the highest odds of nonpersistence with no evidence of interaction. In contrast, expectations for side effects before starting treatment exhibited an important interaction with incident side effects following treatment initiation. Among respondents with incident side effects (n=741, 24.5%), the risk for early nonpersistence was 11.5% if they indicated an expectation for side effects before starting the medication compared to 23.6% if they did not (adjusted OR: 0.38, 95%CI: 0.25-0.60). Conclusion Expectations for side effects may be a previously unrecognized but important marker of the probability to persist with treatment. A high percentage of new medication users appeared unprepared for the possibility of side effects from their new medication making them less resilient if side effects occur.
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Affiliation(s)
- David F Blackburn
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Shenzhen Yao
- Public Health Surveillance Unit, Vancouver Coastal Health Authority, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Jeff G Taylor
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Qais Alefan
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Lisa M Lix
- Department of Community Health Sciences, Max Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dean T Eurich
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Niteesh K Choudhry
- Department of Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, MA, USA
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Chen T, Spiegel T, Zhang H, Celmins L, Bickley D, Scarpelli D. Evaluating the impact of a discharge pharmacy in the emergency department on emergency department revisits and admissions. Am J Emerg Med 2024; 79:116-121. [PMID: 38422752 DOI: 10.1016/j.ajem.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 01/04/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024] Open
Abstract
IMPORTANCE Medication nonadherence leads to worse health outcomes, increased healthcare service utilization, and increased overall healthcare costs. OBJECTIVE To determine whether a discharge pharmacy located in the Emergency Department (ED) reduces ED revisits and hospitalizations. DESIGN This is a cohort study where we extracted data from our electronic medical records with adult encounters between 12/2019-10/2021. For the purpose of this study, we defined a revisit to the ED as within 7 days and an admission within 30 days from prior initial ED visit. SETTING The University of Chicago Medicine is an academic medical center located in Chicago's South Side. PARTICIPANTS Between dates of 12/2019-11/2021, we had 78,660 adult distinct encounters. We created 5 different groups: no medications prescribed, ED discharge pharmacy only, e-prescriptions to outside pharmacies, combination of ED pharmacy and e-prescription sent elsewhere, and printed prescriptions with or without any e-prescriptions. EXPOSURE Our ED pharmacy is located within the adult ED, serving only patients seen and discharged from the adult ED. MAIN OUTCOME(S) AND MEASURE(S) Our primary endpoint is to evaluate if prescribing and dispensing prescriptions from only our ED pharmacy is associated with decreased ED revisits within 7 days and reduced hospitalizations within 30 days of initial ED visit. RESULTS When comparing patients who received prescriptions only from the ED discharge pharmacy, patients who received no prescriptions were 31.6% (P < 0.001) more likely to revisit our ED, and patients who received e-prescriptions sent to other pharmacies were 10.4% (P = 0.017) more likely to revisit. Patients who received e-prescriptions from other pharmacies were 29.2% (P < 0.001) more likely to be hospitalized and mixture of e-prescriptions were 59.5% (P < 0.001) more likely to be hospitalized compared to the ED pharmacy only group. CONCLUSIONS AND RELEVANCE We believe having a pharmacy providing medications to patients being discharged from the ED reduces barriers like cost, transportation, and pharmacy access patients face trying to fill prescriptions at their local pharmacy. All of these reductions in barriers provides an easier and more convenient method for patients to obtain their medications at discharge from the ED, reducing the risk of a repeat ED visit and subsequent hospital admission.
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Affiliation(s)
- Thomas Chen
- Department of Medicine, Section of Hospital Medicine, University of Chicago.
| | - Thomas Spiegel
- Department of Medicine, Section of Emergency Medicine, University of Chicago
| | - Hui Zhang
- Center for Health and the Social Sciences, University of Chicago
| | | | - Daniel Bickley
- Department of Medicine, Section of Emergency Medicine, University of Chicago; Center for Health and the Social Sciences, University of Chicago
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Liu HH, Li S, Zhang Y, Zhang M, Zhang HW, Qian J, Dou KF, Li JJ. Association of β-blocker use at discharge and prognosis of oldest old with acute myocardial infarction: a prospective cohort study. Eur Geriatr Med 2024; 15:169-178. [PMID: 38103145 DOI: 10.1007/s41999-023-00899-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Accepted: 11/11/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE It is uncertain whether β-blockers are beneficial for long-term prognosis in older patients following acute myocardial infarction (AMI). Thus, this study sought to examine the effect of β-blockers on long-term cardiovascular mortality (CVM) in the oldest old (≥ 80 years) with AMI. METHODS In this prospective, consecutive, non-randomized study, a total of 1156 patients with AMI admitted within 24 h after onset of symptoms were enrolled from January 2012 to February 2020. Univariate and multivariate Cox regression analyses were performed to examine the impact of β-blocker use on prognosis. Furthermore, one-to-one propensity score matching (PSM) and inverse probability treatment weighting (IPTW) analyses were used to control for systemic differences between groups. The primary outcome was long-term CVM. RESULTS Among the enrolled subjects, 972 (85.9%) were prescribed with β-blockers at discharge. Over a mean follow-up of 26.3 months, 224 cardiovascular deaths were recorded. Both univariate [hazard ratio (HR), 1.41, 95% confidence interval (CI) 0.93-2.13] and multivariate (HR, 1.29, 95% CI 0.79-2.10) Cox regression analyses showed that β-blocker use had no significant association with the long-term CVM, which was further demonstrated by PSM (HR, 1.31, 95% CI 0.75-2.28) and IPTW (HR, 1.41, 95% CI 0.73-2.69) analyses. Subgroup analyses according to sex, heart rate, hypertension, diabetes, revascularization, left ventricular ejection fraction, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers use showed consistent results as well. CONCLUSION Our findings first suggested that the use of β-blockers at discharge in oldest old with AMI was not useful for reducing post-discharge CVM, which need to be further verified by randomized controlled trials.
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Affiliation(s)
- Hui-Hui Liu
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
- Heart Failure Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sha Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Yan Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Meng Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Hui-Wen Zhang
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Jie Qian
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China
| | - Ke-Fei Dou
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
| | - Jian-Jun Li
- Cardiometabolic Center, State Key Laboratory of Cardiovascular Disease, FuWai Hospital, National Center for Cardiovascular Diseases, National Clinical Research Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 167 BeiLiShi Road, XiCheng District, Beijing, 100037, China.
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Hickson RP, Kucharska-Newton AM, Rodgers JE, Sleath BL, Fang G. Optimal P2Y 12 inhibitor durations in older men and older women following an acute myocardial infarction: A nationwide cohort study using Medicare data. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 36:100339. [PMID: 38487715 PMCID: PMC10939016 DOI: 10.1016/j.ahjo.2023.100339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/26/2023] [Accepted: 10/26/2023] [Indexed: 03/17/2024]
Abstract
Study objective Identify optimal P2Y12 inhibitor durations balancing ischemic-benefit and bleeding-risk outcomes after acute myocardial infarction (AMI) in older men and women. Design Observational retrospective cohort with 2 years of follow-up, using clone-censor-weight marginal structural models to emulate randomization. Setting 20 % sample of US Medicare administrative claims data. Participants P2Y12 inhibitor new users ≥66 years old following 2008-2013 AMI hospitalization. Exposures 12- to 24-month P2Y12 inhibitor durations in 1-month intervals. Main outcome measures Effectiveness outcome (composite of all-cause mortality, recurrent AMI, ischemic stroke), safety outcome (hospitalized bleed), and negative control outcome (heart failure hospitalization). Results Of 28,488 P2Y12 inhibitor new users, 51 % were female, 50 % were > 75 years old, 88 % were White/non-Hispanic, and 93 % initiated clopidogrel. Negative control outcome results for 16- through 24-month durations appeared most likely to meet assumptions of no unmeasured confounding. Compared to men taking 24-month therapy, men taking 16-month therapy had higher 2-year risks of the composite effectiveness outcome (relative risk [RR] = 1.08; 95 % confidence interval [95%CI]:1.00-1.15) with similar bleeding risks (RR = 0.98; 95%CI:0.85-1.13). Compared to women taking 24-month therapy, women taking 16-month therapy had similar 2-year risks of the composite effectiveness outcome (RR = 0.98; 95%CI:0.92-1.04) and lower bleeding risks (RR = 0.88; 95%CI:0.80-0.96). Conclusions Older men taking 24-month P2Y12 inhibitor therapy had the lowest composite effectiveness outcome risk with no increased bleeding risk compared to shorter durations. Women taking 16-month versus 24-month P2Y12 inhibitor therapy had similar composite effectiveness outcome risks but a substantially lower hospitalized bleeding risk, suggesting durations beyond 15-17 months lacked benefit while increasing bleeding risk.
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Affiliation(s)
- Ryan P. Hickson
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States of America
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, United States of America
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, United States of America
- Office of New Drugs, Center for Drug Evaluation and Research, US Food and Drug Administration, United States of America
| | - Anna M. Kucharska-Newton
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, United States of America
- Department of Epidemiology, College of Public Health, University of Kentucky, United States of America
| | - Jo E. Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States of America
| | - Betsy L. Sleath
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States of America
| | - Gang Fang
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, United States of America
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Xia T, Qiu H, Yu B, Bi J, Gu X, Wang S, Zhang Y. Cost-related medication nonadherence in US adults with asthma: The National Health Interview Survey, 2013-2020. Ann Allergy Asthma Immunol 2023; 131:606-613.e5. [PMID: 37499864 DOI: 10.1016/j.anai.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/10/2023] [Accepted: 07/12/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Asthma is a chronic disease that needs long-term control for secondary prevention. Health-related expenditures resulting from asthma are rising in the United States, and medication nonadherence is associated with adverse health outcomes in patients with asthma. OBJECTIVE To estimate the prevalence and risk factors of cost-related medication nonadherence (CRN) in individuals with asthma in the United States. METHODS We identified patients aged above or equal to 18 years with a history of asthma in nationally representative cross-sectional data, the National Health Interview Survey 2013 to 2020. Participants were considered to have experienced CRN if at any time in the 12 months they reported skipping doses, taking less medication, or delaying filling a prescription to save money. The weighted prevalence of CRN was estimated overall and by subgroups. Logistic regression was used to identify CRN-related characteristics. RESULTS Of the 26,539 National Health Interview Survey participants with a history of asthma, 4360 (15.77%; representing 3.92 million of the US population) reported CRN, with 10.12% (weighted 2.51 million) of patients skipping doses to save money, 10.82% (weighted 2.69 million) taking less medication to save money, and 13.35% (weighted 3.31 million) delaying filling a prescription to save money. The subgroups young, women, low income, no health insurance, currently smoking, and with comorbidities had a higher prevalence of CRN. The results of this sensitivity analysis did not differ from the overall results. CONCLUSION In the United States, 1 in 6 adults with a history of asthma is nonadherence with medications due to costs. Removing financial barriers to accessing medication can improve medication adherence in patients with asthma.
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Affiliation(s)
- Tong Xia
- Department of Epidemiology and Biostatistics, School of Public Health, Jiamusi University, Jiamusi, People's Republic of China
| | - Hongbin Qiu
- Department of Epidemiology and Biostatistics, School of Public Health, Jiamusi University, Jiamusi, People's Republic of China
| | - Bo Yu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China; The Key Laboratory of Myocardial Ischemia, Chinese Ministry of Education, Harbin, People's Republic of China
| | - Jinfeng Bi
- Department of Respiratory, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China
| | - Xia Gu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China; The Key Laboratory of Myocardial Ischemia, Chinese Ministry of Education, Harbin, People's Republic of China
| | - Shanjie Wang
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, People's Republic of China; The Key Laboratory of Myocardial Ischemia, Chinese Ministry of Education, Harbin, People's Republic of China.
| | - Yiying Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Jiamusi University, Jiamusi, People's Republic of China.
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8
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Pedersen SB, Nielsen JC, Bøtker HE, Udupi A, Goldberger JJ. Long-Term Follow-Up After Acute Myocardial Infarction According to Beta-Blocker Dose. Am J Med 2023; 136:458-465.e3. [PMID: 36822258 PMCID: PMC10244476 DOI: 10.1016/j.amjmed.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 02/01/2023] [Indexed: 02/23/2023]
Abstract
OBJECTIVE Our purpose was to examine the association between beta-blocker dose and mortality following acute myocardial infarction. METHODS This nationwide cohort study enrolled all patients admitted for first-time acute myocardial infarction in Denmark between July 1, 2004 and December 31, 2014, using the Danish National Patient Registry. Patients alive 15 days after admission were followed until death, emigration, or December 31, 2014. Patients were categorized according to daily beta-blocker consumption (0%, >0%-12.5%, >12.5%-25%, >25%-50%, >50%-100%, or >100% of the currently recommended target dose) based on prescriptions registered in the Danish National Database of Reimbursed Prescriptions. Doses were continuously updated during follow-up. Mortality rate ratios (MRRs) were computed and adjusted for confounders using Cox proportional hazard regression. RESULTS Among 65,125 patients followed, any beta-blocker dose was associated with significant mortality reduction compared with no treatment (adjusted MRR ≤ 0.92 [95% confidence interval {CI}: 0.86-0.98]). The largest reduction was observed within the first year for beta-blocker doses >25%-50% (adjusted MRR = 0.55 [95% CI: 0.50-0.60]). After 1 year, doses >50%-100% were associated with the largest mortality reduction (adjusted MRR = 0.58 [95% CI: 0.50-0.67]), but it did not differ significantly from that associated with doses >25%-50% (adjusted MRR = 0.68 [95% CI: 0.61-0.77]). CONCLUSIONS Any beta-blocker dose was associated with significant mortality reduction following acute myocardial infarction compared with no treatment. Doses >25%-50% of the currently recommended target dose were associated with maximal mortality reduction within the first year after acute myocardial infarction, suggesting that higher doses are unnecessary.
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Affiliation(s)
| | - Jens Cosedis Nielsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Aparna Udupi
- Biostatistical Advisory Service, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Jeffrey J Goldberger
- Division of Cardiology, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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9
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Chen C, Li X, Su Y, You Z, Wan R, Hong K. Adherence with cardiovascular medications and the outcomes in patients with coronary arterial disease: "Real-world" evidence. Clin Cardiol 2022; 45:1220-1228. [PMID: 36116032 DOI: 10.1002/clc.23898] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 07/20/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Cardiovascular medications are vital for the secondary prevention of coronary arterial disease (CAD). However, the effect of cardiovascular medication may depend on the optimal adherence of the patients. This meta-analysis aims to determine the magnitude of adherence to vascular medications that influences the absolute and relative risks (RRs) of mortality in patients with CAD in real-world settings. METHODS The Cochrane Library, PubMed, and EMBASE databases were searched through March 1, 2022. Prospective studies reporting association as RR and 95% confidence interval between cardiovascular medication adherence and any cardiovascular events and/or all-cause mortality in patients with CAD were included. A one-stage robust error meta-regression method was used to summarize the dose-specific relationships. RESULTS A total of 18 studies were included. There is a significant inverse linear association between cardiovascular medication adherence and cardiovascular events (pnonlinearity = .68) or mortality (pnonlinearity = .82). The exposure-effect analysis showed that an improvement of 20% cardiovascular medication adherence was associated with 8% or 12% lower risk of any cardiovascular events or mortality, respectively. In subgroup analysis, the benefit was observed in adherence of stain (RR: 0.90, for cardiovascular events, RR: 0.85, for mortality), angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARB)(RR: 0.90, for mortality), and antiplatelet agent (RR: 0.89 for mortality) but not in beta-blocker (RR: 0.90, p = .14, for cardiovascular events, RR: 0.97, p = .32 for mortality). Estimated absolute differences per 1 million individuals per year for mortality associated with 20% improvement were 175 cases for statin, 129 cases for antiplatelet, and 117 cases for ACEI/ARB. CONCLUSION Evidence from the real word showed poor adherence to vascular medications contributes to a considerable proportion of all cardiovascular disease events and mortality in patients with CAD.
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Affiliation(s)
- Chen Chen
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Xiaoqing Li
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yuhao Su
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Zhigang You
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Rong Wan
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China
| | - Kui Hong
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China.,Department of Genetic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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10
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Schroeder MC, Chapman CG, Chrischilles EA, Wilwert J, Schneider KM, Robinson JG, Brooks JM. Generating Practice-Based Evidence in the Use of Guideline-Recommended Combination Therapy for Secondary Prevention of Acute Myocardial Infarction. PHARMACY 2022; 10:147. [PMID: 36412823 PMCID: PMC9680510 DOI: 10.3390/pharmacy10060147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Clinical guidelines recommend beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers, and statins for the secondary prevention of acute myocardial infarction (AMI). It is not clear whether variation in real-world practice reflects poor quality-of-care or a balance of outcome tradeoffs across patients. Methods: The study cohort included Medicare fee-for-service beneficiaries hospitalized 2007-2008 for AMI. Treatment within 30-days post-discharge was grouped into one of eight possible combinations for the three drug classes. Outcomes included one-year overall survival, one-year cardiovascular-event-free survival, and 90-day adverse events. Treatment effects were estimated using an Instrumental Variables (IV) approach with instruments based on measures of local-area practice style. Pre-specified data elements were abstracted from hospital medical records for a stratified, random sample to create "unmeasured confounders" (per claims data) and assess model assumptions. Results: Each drug combination was observed in the final sample (N = 124,695), with 35.7% having all three, and 13.5% having none. Higher rates of guideline-recommended treatment were associated with both better survival and more adverse events. Unmeasured confounders were not associated with instrumental variable values. Conclusions: The results from this study suggest that providers consider both treatment benefits and harms in patients with AMIs. The investigation of estimator assumptions support the validity of the estimates.
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Affiliation(s)
- Mary C. Schroeder
- Division of Health Services Research, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | - Cole G. Chapman
- Division of Health Services Research, College of Pharmacy, University of Iowa, Iowa City, IA 52242, USA
| | | | - June Wilwert
- Schneider Research Associates, Des Moines, IA 50312, USA
| | | | - Jennifer G. Robinson
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA 52242, USA
| | - John M. Brooks
- Center for Effectiveness Research in Orthopaedics, Arnold School of Public Health, University of South Carolina, Columbia, SC 29208, USA
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11
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Early statin use and cardiovascular outcomes after myocardial infarction: A population-based case-control study. Atherosclerosis 2022; 354:8-14. [DOI: 10.1016/j.atherosclerosis.2022.06.1019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/03/2022] [Accepted: 06/17/2022] [Indexed: 11/21/2022]
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12
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Rodríguez-Bernal CL, Sánchez-Saez F, Bejarano-Quisoboni D, Hurtado I, García-Sempere A, Peiró S, Sanfélix-Gimeno G. Assessing Concurrent Adherence to Combined Essential Medication and Clinical Outcomes in Patients With Acute Coronary Syndrome. A Population-Based, Real-World Study Using Group-Based Trajectory Models. Front Cardiovasc Med 2022; 9:863876. [PMID: 35694663 PMCID: PMC9174582 DOI: 10.3389/fcvm.2022.863876] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/21/2022] [Indexed: 12/02/2022] Open
Abstract
Aim Adherence to multiple medications recommended for secondary prevention of cardiovascular conditions represents a challenge. We aimed to identify patterns of concurrent adherence to combined therapy and assess their impact on clinical outcomes in a cohort of patients with acute coronary syndrome (ACS). Methods Population-based retrospective cohort of all patients discharged after hospitalization for ACS (2009–2011), prescribed ≥3 therapeutic groups within the first month. We assessed monthly concurrent adherence (≥24 days of medication out of 30) to ≥3 medications during the first year, and patterns were identified through group-based trajectory models. A composite clinical outcome during the second year was constructed. The association between adherence patterns and traditional refill adherence metrics [e.g., the proportion of days covered (PDC)], and outcomes were assessed through a multivariable Cox proportional hazards model. Results Among 15,797 patients discharged alive, 12,057 (76.32%) initiated treatment with ≥3 therapeutic groups after discharge. We identified seven adherence trajectories to ≥3 medications: Adherent (52.94% of patients); Early Gap (6.64%); Middle Gap (5.67%); Late Decline (10.93%); Occasional Users (5.45%); Early Decline (8.79%); Non-Adherent (9.58%). Compared to the Adherent group, patients belonging to Early Gap (HR:1.30, 95%CI 1.07;1.60), Late decline (hazards ratio (HR): 1.31, 95% CI 1.1; 1.56), and Non-Adherent trajectories (HR: 1.36, 95% CI 1.14; 1.63) had a greater risk of adverse clinical outcomes, which was also different to the risk ascertained through concurrent PDC < 80 (HR: 1.13, 95% CI 1.01; 1.27). Conclusion Overall, seven adherence trajectories to ≥3 drugs were identified, with three distinct adherence patterns being at higher risk of adverse outcomes. The identification of patterns of concurrent adherence, a more comprehensive approach than traditional measurements, may be useful to target interventions to improve adherence to multiple medications.
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Affiliation(s)
- Clara L. Rodríguez-Bernal
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
- *Correspondence: Clara L. Rodríguez-Bernal
| | - Francisco Sánchez-Saez
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Daniel Bejarano-Quisoboni
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
| | - Isabel Hurtado
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Anibal García-Sempere
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Salvador Peiró
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
| | - Gabriel Sanfélix-Gimeno
- Health Services Research Unit, The Foundation for the Promotion of Health and Biomedical Research of Valencia Region (FISABIO), Valencia, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Valencia, Spain
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13
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Barbieri L, Trabattoni D, Stefanini GG, Vizzardi E, Tumminello G, Assanelli E, Adamo M, Pivato CA, Provenzale G, Gentile D, Metra M, Carugo S. Impact of RAAS Inhibitors on Clinical Outcome and Mortality in Patients With STEMI During the COVID-19 Era: A Multicenter Observational Study. Front Cardiovasc Med 2021; 8:792804. [PMID: 35004902 PMCID: PMC8739948 DOI: 10.3389/fcvm.2021.792804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Accepted: 11/30/2021] [Indexed: 12/02/2022] Open
Abstract
Conflicting results are available regarding the influence of ACEi/ARBs on the risk of COVID-19 infection, while less is known about their impact on the clinical outcome of patients with STEMI diagnosed with COVID-19. Our aim was to evaluate the impact of ACEi/ARBs therapy on in-hospital mortality and clinical outcomes of patients with STEMI during the COVID-19 pandemic. We retrospectively analyzed consecutive patients with STEMI hospitalized from February 20 to May 10, 2020 in four Hospitals in Lombardy. SARS-COV-2 diagnosis was performed by nasopharyngeal swab test. Procedural outcome, respiratory complications, and in-hospital mortality were reported. Univariate and multivariate analyses were performed by logistic regressions. Our population was represented by 182 patients with STEMI, 76.9% of which were males, and mean age was 67 ± 12.5. Hypertension was reported in 53.3%, and 29.1% was treated with ACEi/ARBs. COVID-19 diagnosis was confirmed in 17.1% of the patients. In-hospital mortality (13.2%) was significantly higher in patients with COVID-19 (31 vs. 10%, p = 0.003), even if ejection fraction [OR 0.93 (95% CI) 0.87-0.99; p = 0.03] and respiratory complications [OR 9.39 (95% CI) 1.91-45.9; p = 0.006] were the only two independent predictors. The incidence of COVID-19 infection was not influenced by ACEi/ARBs (16.5 in naïve vs. 18.8%) whose presence on admission did not correlate with respiratory complications or mortality both in the case of discontinuation and maintenance. In conclusion, in a high-risk population, such as that of patients with STEMI, the potential benefit of ACEi/ARB discontinuation in patients with COVID-19 is overcome by its detrimental effect. Intensive care, additional preventive respiratory investigations, regardless of swab test result, should be suggested for all patients admitted for STEMI during the pandemic.
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Affiliation(s)
- Lucia Barbieri
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Giulio G. Stefanini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Enrico Vizzardi
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gabriele Tumminello
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carlo A. Pivato
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Giovanni Provenzale
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Domitilla Gentile
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Stefano Carugo
- Cardiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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14
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Alefan Q, Yao S, Taylor JG, Lix LM, Eurich D, Choudhry N, Blackburn DF. Factors associated with early nonpersistence among patients experiencing side effects from a new medication. J Am Pharm Assoc (2003) 2021; 62:717-726.e5. [PMID: 34980560 DOI: 10.1016/j.japh.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Drug discontinuation (i.e., nonpersistence) is often attributed to the emergence of adverse effects. However, it is not known whether other factors increase the risk of nonpersistence when adverse effects occur. OBJECTIVES To identify factors associated with early nonpersistence among patients experiencing adverse effects from newly prescribed medications. METHODS A questionnaire was mailed to new users of antihypertensive, antihyperglycemic, and lipid-lowering medications in Saskatchewan, Canada, between 2019 and 2020. Only respondents experiencing adverse effects were included. Responses were compared between the nonpersistent group (i.e., people who had discontinued their medication) and the persistent group (i.e., those who were taking their medication at the time of the survey). Statistically significant factors were tested in multivariable logistic regression models. Odds ratios (ORs) and 95% CIs were reported. RESULTS Of the 3973 returned questionnaires, 813 respondents experienced adverse -effects from their new medication and were included in the study. Of these, 143 respondents (17.5%) had stopped their medication at the time of survey completion; most discontinuations (72.1%) occurred within 1 month of the first dose. Nonpersistent patients were older, had lower income, and were less likely to be taking an antihyperglycemic medication. After covariate adjustment, 6 factors were independently associated with nonpersistence: age less than 65 years (OR 1.56 [95% CI 1.01-2.41]), female sex (1.67 [1.08-2.59]), health condition not considered dangerous (2.09 [1.25-3.51]), medication not considered important for health (6.90 [4.40-10.84]), failure to expect adverse effects before starting medication (2.67 [1.74-4.10]), and taking 2 or more medications (0.45 [0.27-0.73]). CONCLUSION Despite the strong link between the emergence of adverse effects and early nonpersistence, our findings confirm that this association is highly influenced by several factors external to the physical experiences caused by the new medication.
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15
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Chen CW, Lin YC, Shih CM, Chen WT, Lin FY, Bi WF, Kao YT, Chiang KH, Chan CS, Hsu CY, Yang TL, Hsiao CY, Hsiao BY, Chien LN, Huang CY. Association of multiple preventive therapies postdischarge and long-term health outcomes after acute myocardial infarction. J Chin Med Assoc 2021; 84:1084-1091. [PMID: 34561408 DOI: 10.1097/jcma.0000000000000621] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Statins, beta-blockers, and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers have been advocated by guidelines as secondary prevention medications to improve the long-term outcomes of post-acute myocardial infarction (AMI) patients. However, adequate drug adherence has always been challenging, and different treatment regimens may lead to divergent outcomes that remain unclear under current myocardial infarction (MI) care standards. This study investigated the association between use of different preventive regimens post-AMI and patients' long-term outcomes. METHODS This cohort study used data files from the Taiwan National Health Insurance Research Database. A total of 77 520 people who were hospitalized with AMI between 2002 and 2015 were assessed. On the basis of medication possession ratio (MPR) to individual medications, eight treatment groups were examined in this study. Receiving therapy was defined as MPR ≥40%. We investigated the association between different treatment groups and all-cause mortality in 24 months. RESULTS Overall, 51 322 patients with ST-elevation MI and 26 198 with non-ST-elevation MI were included in the study. Patients received all three preventive medications show the lowest mortality in 24 months follow-up periods among all treatment groups. Patients who did not usage of any of these three preventive medications had the highest mortality in 24 months (adjusted hazard ratio, 1.78; 95% CI, 1.64-1.93). This mortality rate had the same pattern across the three cohort generations (2002-2005, 2006-2010, and 2011-2015). CONCLUSION In this large population-based real-world study, usage of three preventive therapies post-MI was associated with the lowest rate of all-cause mortality.
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Affiliation(s)
- Chih-Wei Chen
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yi-Cheng Lin
- Department of Pharmacy, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chun-Ming Shih
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Wan-Ting Chen
- Office of Data Center, Taipei Medical University, Taipei, Taiwan, ROC
| | - Feng-Yen Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Wei-Fung Bi
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yung-Ta Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Kuang-Hsing Chiang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chao-Shun Chan
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chien-Yi Hsu
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Tsung-Lin Yang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
| | - Cheng-Yi Hsiao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Bu-Yuan Hsiao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
| | - Li-Nien Chien
- Office of Data Center, Taipei Medical University, Taipei, Taiwan, ROC
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chun-Yao Huang
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Research Center, Taipei Medical University Hospital, Taipei, Taiwan, ROC
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan, ROC
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan, ROC
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16
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Hickson RP, Kucharska-Newton AM, Rodgers JE, Sleath BL, Fang G. Disparities by sex in P2Y 12 inhibitor therapy duration, or differences in the balance of ischaemic-benefit and bleeding-risk clinical outcomes in older women versus comparable men following acute myocardial infarction? A P2Y 12 inhibitor new user retrospective cohort analysis of US Medicare claims data. BMJ Open 2021; 11:e050236. [PMID: 34853104 PMCID: PMC8638457 DOI: 10.1136/bmjopen-2021-050236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To determine if comparable older women and men received different durations of P2Y12 inhibitor therapy following acute myocardial infarction (AMI) and if therapy duration differences were justified by differences in ischaemic benefits and/or bleeding risks. DESIGN Retrospective cohort. SETTING 20% sample of 2007-2015 US Medicare fee-for-service administrative claims data. PARTICIPANTS ≥66-year-old P2Y12 inhibitor new users following 2008-2013 AMI hospitalisation (N=30 613). Older women compared to older men with similar predicted risks of study outcomes. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome: P2Y12 inhibitor duration (modelled as risk of therapy discontinuation). SECONDARY OUTCOMES clinical events while on P2Y12 inhibitor therapy, including (1) death/hospice admission, (2) composite of ischaemic events (AMI/stroke/revascularisation) and (3) hospitalised bleeds. Cause-specific risks and relative risks (RRs) estimated using Aalen-Johansen cumulative incidence curves and bootstrapped 95% CIs. RESULTS 10 486 women matched to 10 486 men with comparable predicted risks of all 4 study outcomes. No difference in treatment discontinuation was observed at 12 months (women 31.2% risk; men 30.9% risk; RR 1.01; 95% CI 0.97 to 1.05), but women were more likely than men to discontinue therapy at 24 months (54.4% and 52.9% risk, respectively; RR 1.03; 95% CI 1.00 to 1.05). Among patients who did not discontinue P2Y12 inhibitor therapy, women had lower 24-month risks of ischaemic outcomes than men (13.1% and 14.7%, respectively; RR 0.90; 95% CI 0.84 to 0.96), potentially lower 24-month risks of death/hospice admission (5.0% and 5.5%, respectively; RR 0.91; 95% CI 0.82 to 1.02), but women and men both had 2.5% 24-month bleeding risks (RR 0.98; 95% CI 0.82 to 1.14). CONCLUSIONS Risks for death/hospice and ischaemic events were lower among women still taking a P2Y12 inhibitor than comparable men, with no difference in bleeding risks. Shorter P2Y12 inhibitor durations in older women than comparable men observed between 12 and 24 months post-AMI may reflect a disparity that is not justified by differences in clinical need.
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Grants
- T32 HL007055 NHLBI NIH HHS
- UL1 TR001111 NCATS NIH HHS
- Pharmacoepidemiology Gillings Innovation Lab (PEGIL)
- Geriatric Research, Education, and Clinical Center at the Veterans Affairs Healthcare System, Pittsburgh, PA
- American Foundation for Pharmaceutical Education
- School of Medicine, University of North Carolina at Chapel Hill
- National Heart, Lung, and Blood Institute
- the CER Strategic Initiative of UNC’s Clinical and Translational Science Award
- Cecil G. Sheps Center for Health Services Research, UNC
- Center for Pharmacoepidemiology, Department of Epidemiology, UNC Gillings School of Global Public Health
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Affiliation(s)
- Ryan P Hickson
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Anna M Kucharska-Newton
- Department of Epidemiology, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, Kentucky, USA
| | - Jo E Rodgers
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Betsy L Sleath
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gang Fang
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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17
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Sud M, Ko DT, Chong A, Koh M, Azizi PM, Austin PC, Stukel TA, Jackevicius CA. Renin-angiotensin-aldosterone system inhibitors and major cardiovascular events and acute kidney injury in patients with coronary artery disease. Pharmacotherapy 2021; 41:988-997. [PMID: 34496067 DOI: 10.1002/phar.2624] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 07/11/2021] [Accepted: 07/14/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Renin-angiotensin-aldosterone system inhibitors (RAASIs) are recommended for most patients with coronary artery disease (CAD). However, there is debate across guidelines as to which patients with CAD benefit the most from these agents. This study investigated the association between RAASIs and cardiovascular outcomes and acute kidney injury in a contemporary cohort of patients with CAD. METHODS Patients ≥65 years of age with CAD alive on April 1, 2012 in Ontario, Canada were included. Outcomes included major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction (MI), unstable angina, stroke, or coronary revascularization), and acute kidney injury (AKI) hospitalizations at 4 years. Inverse probability of treatment-weighted Cox proportional hazards regression models was used to compare the rates of each outcome in patients treated with and without RAASIs (angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers). RESULTS There were 165,058 patients with CAD identified (mean age 75 years, 65.5% male, 64.7% prescribed RAASIs). After inverse-probability weighting, treatment with RAASIs was associated with a lower rate of MACE compared with treatment without RAASIs (17.6% vs 18.2%, hazard ratio [HR]: 0.96, 95% CI: 0.93-0.99, respectively). However, treatment with RAASIs was associated with a higher rate of AKI compared with treatment without RAASIs (1.7% vs 1.5%, HR: 1.14, 95% CI: 1.02-1.29, respectively). The reduction in MACE was greater in patients with prior MI (HR: 0.87, 95% CI: 0.82-0.92) compared with patients without prior MI (HR: 1.00, 95% CI: 0.97-1.04, interaction p < 0.01). The increase in AKI was lower in patients with prior MI (HR: 0.82, 95% CI: 0.66-1.00) compared with patients without prior MI (HR: 1.37, 95% CI: 1.19-1.57, interaction p < 0.01). CONCLUSIONS This study supports the continued use of RAASIs in patients with CAD, although the benefit appears smaller in magnitude than observed in prior trials. High-risk patients, particularly those with prior MI, appear to benefit the most from RAASIs.
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Affiliation(s)
- Maneesh Sud
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dennis T Ko
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | - Paymon M Azizi
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Thérèse A Stukel
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Western University of Health Services, Pomona, California, USA.,VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
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18
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Khan R, Kaul P, Islam S, Savu A, Bagai A, van Diepen S, Bainey KR, Welsh RC, Goodman SG. Drug Adherence and Long-Term Outcomes in Non-Revascularized Patients Following Acute Myocardial Infarction. Am J Cardiol 2021; 152:49-56. [PMID: 34120704 DOI: 10.1016/j.amjcard.2021.04.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022]
Abstract
This study examined long-term outcomes and adherence to guideline-based medications in non-revascularized acute myocardial infarction (MI) patients undergoing and not undergoing angiography. We analyzed non-revascularized MI patients hospitalized in Alberta, Canada between 2010-2016 and categorized them according to whether they had undergone coronary angiography. Adherence to guideline-based medications was determined by the proportion of days covered (PDC) and subdivided into categories based on PDC: 0% (none), 1-40% (low), 40-79% (intermediate) and ≥ 80% (high). Patients not undergoing angiography were older, less frequently male, and had more comorbidities. Those not receiving angiography had higher rates of 2-year myocardial infarction (9.9% vs 6.1%, p <0.001), heart failure (14.9% vs 6.1%, p <0.001), and mortality (29.4% vs 7.4%, p <0.001). Optimal medial therapy (OMT), defined by high PDC for the combination of lipid-modifying agents, β-blockers and angiotensin converting enzyme-inhibitors/receptor blockers (ACE-I/ARBs), was achieved in 32.9%. Patients not undergoing angiography had lower rates of OMT adherence (p <0.001). In patients not undergoing angiography, high-adherence to lipid-modifying agents (HR 0.70 [95% CI 0.57-0.87]), β-blockers (HR 0.78 [0.62-0.97]), ACE-I/ARBs (HR 0.64 [0.52-0.79]) and OMT (HR 0.56 [0.40-0.77]) was independently associated with lower 2-year mortality. In conclusion, MI patients not receiving angiography had low adherence rates to guideline-based pharmacotherapies and high rates of long-term outcomes, suggesting potential treatment targets to improve prognosis in non-invasively managed MI patients.
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19
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Lebedev PA, Petrukhina IK, Garanin AA, Paranina EV. Optimal Medical Therapy for Chronic Coronary Syndrome: Realities and Prospects. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-06-17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Combination therapy is the standard of treatment for virtually all current non-communicable diseases, primarily chronic coronary heart disease, in modern terminology - "chronic coronary syndrome" (CSS), arterial hypertension, chronic heart failure, diabetes mellitus. The need for a combination of drugs increases even more with comorbidity, which is a typical situation in clinical practice. The recently accumulated material requires a review of the possibility of percutaneous coronary intervention and coronary bypass surgery in prolonging the life of patients with CCS, focusing on providing optimal medical therapy (OMT) for each patient with CCS, based on long-term treatment with antiplatelet agents, statins, angiotensin converting enzyme in-hibitors/angiotensin receptor blockers, beta-blockers. OMT aimed at preventing cardiovascular events and relieving symptoms in patients with CCS requires maximum commitment - a key factor in achieving therapeutic goals. Insufficient adherence of patients to prescribed therapy and its absence are the main barriers to increasing the survival rate of patients with cardiovascular diseases in primary and secondary prevention in the Russian Federation, as evidenced by numerous registers. The desire of the doctor to individualize treatment, which inevitably complicates the use of drugs, pushes patient adherence to treatment into the background. As a result, the patient's lack of commitment to each of the pharmaceuticals destroys the applicability of the OMT concept. A great achievement of the current stage of development of clinical cardiology and the pharmaceutical industry is the ability to offer patients optimal single pill combinations (SPC) in terms of effectiveness, tolerability, drug interactions, and ease of use. The article substantiates the prospects for a successful solution of this key problem by using a new generation of SPC components belonging to different pharmacological groups. The combination of three components (lisinopril, amlodipine and rosuvastatin), each of which has pleiotropic effects, provides a multi-targeted effect with a single dose, with the possibility of individualization of therapy, which is provided by four dosage options within this SPC.
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20
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Zhang T, Guan YZ, Liu H. Association of Acidemia With Short-Term Mortality of Acute Myocardial Infarction: A Retrospective Study Base on MIMIC-III Database. Clin Appl Thromb Hemost 2021; 26:1076029620950837. [PMID: 32862673 PMCID: PMC7466881 DOI: 10.1177/1076029620950837] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Acute myocardial infarction (AMI) is a leading cause of death and not a few of these patients are combined with acidemia. This study aimed to detect the association of acidemia with short-term mortality of AMI patients. A total of 972 AMI patients were selected from the Medical Information Mart for Intensive Care (MIMIC) III database for analysis. Propensity-score matching (PSM) was used to reduce the imbalance. Kaplan-Meier survival analysis was used to compare the mortality, and Cox-proportional hazards model was used to detect related factors associated with mortality. After PSM, a total of 345 non-acidemia patients and 345 matched acidemia patients were included. The non-acidemia patients had a significantly lower 30-day mortality (20.0% vs. 28.7%) and lower 90-day mortality (24.9% vs. 31.9%) than the acidemia patients (P < 0.001 for all). The severe-acidemia patients (PH < 7.25) had the highest 30-day mortality (52.6%) and 90-day mortality (53.9%) than non-acidemia patients and mild-acidemia (7.25 ≤ PH < 7.35) patients (P < 0.001). In Cox-proportional hazards model, acidemia was associated with improved 30-day mortality (HR = 1.518; 95%CI = 1.110-2.076, P = 0.009) and 90-day mortality (HR = 1.378; 95%CI = 1.034 -1.837, P = 0.029). These results suggest that severe acidemia is associated with improved 30-day mortality and 90-day mortality of AMI patients.
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Affiliation(s)
- Tang Zhang
- Department of Cardiology, The Second Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Yao-Zong Guan
- Department of Cardiology, Institute of Cardiovascular Diseases, The First Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hao Liu
- Department of Cardiology, The Second Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
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21
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Padilla López A. Statin adherence and health outcomes after st-elevation myocardial infarction: 1-year follow-up study. Rev Clin Esp 2021; 221:331-340. [PMID: 32571522 DOI: 10.1016/j.rce.2020.04.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 02/21/2020] [Accepted: 04/17/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES There is deficient control of dyslipidaemia after ST-elevation myocardial infarction (STEMI) despite high rates of statin prescription. The aim of this study was to estimate the rate of statin treatment adherence after a first type 1 STEMI episode, the factors that determine the adherence and its impact on cardiovascular outcomes during the first year of progression. DESIGN We conducted an observational retrospective study with a cohort of patients hospitalised between 2008 and 2013, with an active statin prescription during the first year of follow-up. MATERIAL AND METHODS We determined the adherence using the proportion of days covered. The relationship between compliance and the rest of the variables was determined with a binary logistic regression analysis. Competing risk analysis assessed the relationship between cardiovascular mortality or new vascular event with adherence. RESULTS The study included 552 patients (64.7 ± 13.7; 73.9% men) of the 613 analysed. There was less adherence among foreign nationals, smokers and individuals with hepatic impairment. Compliance was greater starting at 50 years of age, among pensioners and those with dyslipidaemia, obesity and kidney failure and in cases of compliance with the rest of the groups indicated in secondary prevention. Compliance reduced cardiovascular mortality (1.9% vs. 9.1%; HR 0.201; 95% CI 0.075-0.539; p = .001) but not the onset of a new cardiovascular event (5.5% vs. 6.5%; p = .834). CONCLUSIONS Statin adherence during the first year after a STEMI is a key factor in mortality, a period in which its assessment is needed beyond the prescription.
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Affiliation(s)
- A Padilla López
- Servicio de Farmacia de Área, Departamento de Salud de Valencia Clínico-Malvarrosa, Valencia, España.
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22
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Qu X, Yao H, Chen C, Kong S, Sun L, Du L, Liang S, Gao Z, Zheng G, Zheng M, Zhao C, Feng X, Wu G, Zhou H. Spironolactone Improves the All-Cause Mortality and Re-Hospitalization Rates in Acute Myocardial Infarction with Chronic Kidney Disease Patients. Front Pharmacol 2021; 12:632978. [PMID: 34135751 PMCID: PMC8201517 DOI: 10.3389/fphar.2021.632978] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 05/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Mineralocorticoid receptor antagonists (MRA) improve outcomes in chronic kidney disease (CKD) and acute myocardial infarction (AMI) patients. However, the lack of evidence regarding long-term clinical outcomes in the use of MRA, including spironolactone, in patients with AMI combined with CKD. Objectives: This study aimed to investigate whether spironolactone could significantly reduce the risk of all-cause mortality and re-admission in patients with AMI and CKD. Methods: In this single center, observational, retrospective, registry based clinical study, a total of 2,465 AMI patients were initially screened; after excluding patients with estimated glomerular filtration rate more than 60 ml/min/1.73 m2, 360 patients in the standard treatment group and 200 patients in the spironolactone group met the criteria. All enrolled patients follow-up for 30 months. The primary outcomes were all-cause mortality and re-admission. The key safety outcome was hyperkalemia rates during the 30 months follow-up period. Results: 160 (44.4%) and 41 (20.5%) patients in the standard treatment and spironolactone groups died, respectively [hazard ratio (HR): 0.389; 95% confidence interval (CI): 0.276–0.548; p < 0.001]. Re-admission occurred in 217 (60.3%) and 95 (47.5%) patients in the standard treatment and spironolactone groups, respectively (HR: 0.664; 95% CI: 0.522–0.846; p = 0.004). The spironolactone group was divided into two based on the daily dose, low dose group (no more than 40 mg) and high dose group (more than 40 mg); the differences in the mortality rate between low dose group (16.7%) and the standard treatment group (44.4%) (HR: 0.309; 95% CI: 0.228–0.418; p < 0.001) and high dose group (34.1%) (HR: 0.429; 95% CI: 0.199–0.925; p = 0.007) were significant. The differences in re-hospitalization rate between low dose group (43.6%) and the standard treatment group (60.3%) (HR: 0.583; 95% CI: 0.457–0.744; p < 0.001) and high dose group (61.4%) (HR: 0.551; 95% CI: 0.326–0.930; p = 0.007) was significant. Hyperkalemia occurred in 18 (9.0%) and 18 (5.0%) patients in the spironolactone group and standard treatment group, respectively (HR: 1.879; 95% CI: 0.954–3.700; p = 0.068). Whereas, Hyperkalemia occurred in high dose group (20.5%) significantly more often than in the standard treatment group (p < 0.001) and low dose group (5.8%) (p = 0.003). Conclusion: Using MRA, such as spironolactone, may substantially reduce the risk of both all-cause mortality and re-admission in patients with AMI and CKD; the use of low-dose spironolactone has the best efficacy and safety. However, this was a relatively small sample size, single center, observational, retrospective, registry based clinical study and further prospective evaluation in adequately powered randomized trials were needed before further use of spironolactone in AMI with CKD population.
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Affiliation(s)
- Xiang Qu
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Hui Yao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Changxi Chen
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Shuting Kong
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Lingyue Sun
- Department of Cardiology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Leilei Du
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Siqi Liang
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Zhan Gao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Gaoshu Zheng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Minghua Zheng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Chuhuan Zhao
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Xiafei Feng
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Gaojun Wu
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
| | - Hao Zhou
- Cardiovascular Medicine, First Affiliated Hospital of Wenzhou Medical University, The Key Lab of Cardiovascular Disease of Wenzhou, Wenzhou, China
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23
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Padilla López A. Statin adherence and health outcomes after st-elevation myocardial infarction: 1-year follow-up study. Rev Clin Esp 2021; 221:331-340. [PMID: 34059230 DOI: 10.1016/j.rceng.2020.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 04/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVES There is deficient control of dyslipidaemia after ST-elevation myocardial infarction (STEMI) despite high rates of statin prescription. The aim of this study was to estimate the rate of statin treatment adherence after a first type 1 STEMI episode, the factors that determine the adherence and its impact on cardiovascular outcomes during the first year of progression. DESIGN We conducted an observational retrospective study with a cohort of patients hospitalised between 2008 and 2013, with an active statin prescription during the first year of follow-up. MATERIAL AND METHODS We determined the adherence using the proportion of days covered. The relationship between compliance and the rest of the variables was determined with a binary logistic regression analysis. Competing risk analysis assessed the relationship between cardiovascular mortality or new vascular event with adherence. RESULTS The study included 552 patients (64.7 ± 13.7; 73.9% men) of the 613 analysed. There was less adherence among foreign nationals, smokers and individuals with hepatic impairment. Compliance was greater starting at 50 years of age, among pensioners and those with dyslipidaemia, obesity and kidney failure and in cases of compliance with the rest of the groups indicated in secondary prevention. Compliance reduced cardiovascular mortality (1.9% vs. 9.1%; HR 0.201; 95% CI 0.075-0.539; p = .001) but not the onset of a new cardiovascular event (5.5% vs. 6.5%; p = .834). CONCLUSIONS Statin adherence during the first year after a STEMI is a key factor in mortality, a period in which its assessment is needed beyond the prescription.
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Affiliation(s)
- A Padilla López
- Servicio de Farmacia de Área, Departamento de Salud de Valencia Clínico-Malvarrosa, Valencia, Spain.
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24
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El Nasasra A, Beigel R, Klempfner R, Alnsasra H, Matetzky S, Iakobishvili Z, Rubinshtein R, Halabi M, Blatt A, Zahger D. Comparison of Outcomes with or without Beta-Blocker Therapy After Acute Myocardial Infarction in Patients Without Heart Failure or Left Ventricular Systolic Dysfunction (from the Acute Coronary Syndromes Israeli Survey [ACSIS]). Am J Cardiol 2021; 143:1-6. [PMID: 33359228 DOI: 10.1016/j.amjcard.2020.12.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
The contemporary benefit of routine beta-blocker therapy following myocardial infraction in the absence of heart failure or left ventricular systolic dysfunction is unclear. We investigated the impact of beta-blockers on post myocardial infarction outcome in patients without heart failure or left ventricular systolic dysfunction among patients enrolled in the biennial Acute Coronary Syndrome Israeli Surveys. MACE rates at 30 days and overall mortality at one year were compared among patients discharged on beta-blockers versus not, after multivariate analysis to adjust for baseline differences. Between the years 2000 to 2016, data from 15.211consecutive ACS patients were collected. Of 7,392 patients who met the inclusion criteria, 6007 (79.9%) were discharged on beta-blocker therapy. Prescription of beta-blockers at discharge increased modestly from 32% to 38% over the 16-year period. The 30-day MACE rates were similar in patients on vs. not on beta-blockers at discharge (9.0% and 9.5%, respectively). One year survival did not differ significantly between those on vs. not on beta-blockers (HR 0.8, 95% CI 0.58 to 1.11, p = 0.18).In conclusion, beta-blocker therapy did not affect 30 days MACE or 1-year survival after myocardial infarction in patients without heart failure or reduced ejection fraction.
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Affiliation(s)
- Aref El Nasasra
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel.
| | - Roy Beigel
- Leviev Heart Center, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Robert Klempfner
- Leviev Heart Center, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hilmi Alnsasra
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
| | - Shlomi Matetzky
- Leviev Heart Center, Sheba Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Ronen Rubinshtein
- Department of Cardiology, Edith Wolfson Medical Center, Holon and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Majdi Halabi
- Department of Cardiology, Ziv Medical Center, Faculty of Medicine, Bar-Ilan University, Tsfat, Israel
| | - Alex Blatt
- Department of Cardiology, Kaplan Medical Center, Rehovot, Hadassah - Hebrew University School of Medicine, Israel
| | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel
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25
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Soldati S, Di Martino M, Castagno D, Davoli M, Fusco D. In-hospital myocardial infarction and adherence to evidence-based drug therapies: a real-world evaluation. BMJ Open 2021; 11:e042878. [PMID: 33550255 PMCID: PMC7925929 DOI: 10.1136/bmjopen-2020-042878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES This study aimed to measure adherence to chronic polytherapy following an acute myocardial infarction (AMI) and to find out associations between adherence and the setting of AMI onset (in vs out of hospital) as well as other determinants. DESIGN Retrospective follow-up study. SETTING Population living in the Lazio Region, Italy. PARTICIPANTS This study included 25 779 hospitalised patients with a first diagnosis of AMI in 2012-2016, after the exclusion of those with hospital admission for AMI or related causes in the previous 5 years. PRIMARY AND SECONDARY OUTCOME MEASURES Patients were classified as in-hospital AMI (IH-AMI) or out of hospital AMI (OH-AMI) according to present-on-admission codes. Adherence was measured based on prescription claims during a 6-month follow-up after hospital discharge, using medication possession ratio (MPR). Adherence to chronic polytherapy was defined as MPR ≥75% to at least 3 of the following medications: antithrombotics, betablockers, ACE inhibitors/angiotensin receptor blockers and statins. RESULTS Among the entire cohort, 1 044 (4%) patients suffered IH-AMI. Overall, 15 440 (60%) patients were deemed adherent to chronic polytherapy. Female gender, older age, mental disorders, renal disease, asthma and ongoing concomitant treatments were factors associated with poor adherence. By contrast, patients with more severe AMI and those already taking evidence-based (E-B) drugs were more likely to be adherent. A strong association between the setting of AMI onset and adherence was observed: IH-AMI patients were 46% less likely to be adherent to E-B medications during their 6-month follow-up as compared with OH-AMI patients (OR 0.54; 95% CI 0.47 to 0.62; p<0.001). CONCLUSION Pharmacotherapy is not consistent with clinical guidelines, especially for IH-AMI patients. Our findings provide evidence on a previously unidentified groups of patients at risk for poor adherence, who might benefit from greater medical attention and dedicated healthcare interventions.
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Affiliation(s)
- Salvatore Soldati
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Davide Castagno
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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26
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Fang G, Annis IE, Elston-Lafata J, Cykert S. Applying machine learning to predict real-world individual treatment effects: insights from a virtual patient cohort. J Am Med Inform Assoc 2021; 26:977-988. [PMID: 31220274 DOI: 10.1093/jamia/ocz036] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/09/2019] [Accepted: 03/08/2019] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE We aimed to investigate bias in applying machine learning to predict real-world individual treatment effects. MATERIALS AND METHODS Using a virtual patient cohort, we simulated real-world healthcare data and applied random forest and gradient boosting classifiers to develop prediction models. Treatment effect was estimated as the difference between the predicted outcomes of a treatment and a control. We evaluated the impact of predictors (ie, treatment predictors [X1], confounders [X2], treatment effects modifiers [X3], and other outcome risk factors [X4]) with known effects on treatment and outcome using real-world data, and outcome imbalance on predicting individual outcome. Using counterfactuals, we evaluated percentage of patients with biased predicted individual treatment effects. RESULTS The X4 had relatively more impact on model performance than X2 and X3 did. No effects were observed from X1. Moderate-to-severe outcome imbalance had a significantly negative impact on model performance, particularly among subgroups in which an outcome occurred. Bias in predicting individual treatment effects was significant and persisted even when the models had a 100% accuracy in predicting health outcome. DISCUSSION Inadequate inclusion of the X2, X3, and X4 and moderate-to-severe outcome imbalance may affect model performance in predicting individual outcome and subsequently bias in predicting individual treatment effects. Machine learning models with all features and high performance for predicting individual outcome still yielded biased individual treatment effects. CONCLUSIONS Direct application of machine learning might not adequately address bias in predicting individual treatment effects. Further method development is needed to advance machine learning to support individualized treatment selection.
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Affiliation(s)
- Gang Fang
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Izabela E Annis
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer Elston-Lafata
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Samuel Cykert
- Program for Health and Clinical Informatics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Sawano M, Katsuki T, Kitai T, Tamita K, Obunai K, Ikegami Y, Yamane T, Ueda I, Endo A, Maekawa Y, Kawamura A, Fukuda K, Kohsaka S. Beta blockers versus calcium channel blockers for provocation of vasospastic angina after drug-eluting stent implantation: a multicentre prospective randomised trial. Open Heart 2020; 7:openhrt-2020-001406. [PMID: 33087441 PMCID: PMC7580072 DOI: 10.1136/openhrt-2020-001406] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/11/2020] [Accepted: 09/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background Drug-eluting stent-induced vasospastic angina (DES-VSA) has emerged as a novel complication in the modern era of percutaneous coronary intervention (PCI). Although beta blockers (BBs) are generally recommended for coronary heart disease, they may promote incidence of DES-VSA. This study aimed to compare the effects of calcium channel blockers (CCBs) perceived to be protective against DES-VSA and BBs on subsequent coronary events after second-generation drug-eluting stent implantation. Methods In this multicentre prospective, randomised study, 52 patients with coronary artery disease who underwent PCI for a single-vessel lesion with everolimus-eluting stent placement were randomised into post-stenting BB (N=26) and CCB (N=26) groups and followed for 24 months to detect any major cardiovascular events (MACE). A positive result on acetylcholine provocation testing during diagnostic coronary angiography (CAG) at 9 months was the primary endpoint for equivalence. MACE included all-cause death, non-fatal myocardial infarction, unstable angina, cerebrovascular disease or coronary revascularisation for stable coronary artery disease after index PCI. Results At 9 months, 42 patients (80.8%) underwent diagnostic coronary angiography and acetylcholine provocation testing. Among them, seven patients in each group were diagnosed with definite vasospasm (intention-to-treat analysis 26.9% vs 26.9%, risk difference 0 (−0.241, 0.241)). Meanwhile, the secondary endpoint, 24-month MACE, was higher in the CCB group (19.2%) than in the BB group (3.8%) (p=0.01). In detail, coronary revascularisation for stable coronary artery disease was the predominant endpoint that contributed to the greater proportion of MACE in the CCB group (CCB (19.2%) vs BB (3.8%), p=0.03). Conclusions The incidence of acetylcholine-induced coronary artery spasms did not differ between patients receiving BBs or CCBs at 9 months after PCI. However, a higher incidence of 2-year MACE was observed in the CCB group, suggesting the importance of BB administration. Trial registration number This study was registered at the Japanese University Hospital Medical Information Network (UMIN) Clinical Trial Registry (The Prospective Randomized Trial for Optimizing Medical Therapy After Stenting: Calcium-Beta Trial; UMIN000008321, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000009536).
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Affiliation(s)
- Mitsuaki Sawano
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Department of Cardiology, Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Toshiomi Katsuki
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Koichi Tamita
- Department of Cardiology, Nishinomiya Watanabe Cardiovascular Center, Nishinomiya, Hyogo, Japan
| | - Kotaro Obunai
- Department of Cardiology, Tokyo Bay Urayasu Ichikawa Medical Center, Ichikawa, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Hospital Organisation Tokyo Medical Center, Meguro-ku, Tokyo, Japan
| | - Takafumi Yamane
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Ikuko Ueda
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Ayaka Endo
- Department of Cardiology, Saiseikai Central Hospital, Minato-ku, Tokyo, Japan
| | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Akio Kawamura
- Department of Cardiology, International University of Health and Welfare Faculty of Medicine Graduate School of Medicine, Narita, Chiba, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
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Yao X, Shah ND, Gersh BJ, Lopez-Jimenez F, Noseworthy PA. Assessment of Trends in Statin Therapy for Secondary Prevention of Atherosclerotic Cardiovascular Disease in US Adults From 2007 to 2016. JAMA Netw Open 2020; 3:e2025505. [PMID: 33216139 PMCID: PMC7679951 DOI: 10.1001/jamanetworkopen.2020.25505] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Atherosclerotic cardiovascular disease (ASCVD) is highly prevalent in the US, with studies indicating substantial rates of nonadherence to and undertreatment with statin therapy. The 2013 American College of Cardiology/American Heart Association guideline recommended high-intensity statins for all patients age 75 years and younger with documented ASCVD in whom such therapy is tolerated, but there is limited evidence documenting population trends of statin use, adherence, and outcomes in the periods before and after the update to the guideline. OBJECTIVE To assess trends in the use, adherence, cost, and outcomes of statin therapy for secondary prevention in patients with different types of ASCVD between 2007 and 2016. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the OptumLab Data Warehouse database containing privately insured and Medicare Advantage enrollees with demographic characteristics similar to the national US population. Participants were adult patients (age ≥21 years) who had their first ASCVD event between January 1, 2007, and December 31, 2016. Data were characterized as belonging to 3 groups: (1) cardiovascular heart disease (CHD); (2) ischemic stroke or transient ischemic attack (TIA); and (3) peripheral artery disease (PAD). Data were analyzed from July 1 to August 1, 2018. EXPOSURES Calendar year of the initial ASCVD event. MAIN OUTCOMES AND MEASURES Trends in the statin use (within 30 days of discharge from hospitalization), adherence (proportion of days covered ≥80% within the first year), cost, major adverse cardiac events (1-year cumulative risk), and statin intolerance (within the first year). RESULTS Of the 284 954 patients with a new ASCVD event, 128 422 (45.1%) were women; the median age was 63 years (interquartile range [IQR], 54-72 years); 207 781 (72.9%) were White. The use of statins increased from 50.3% in 2007 to 59.9% in 2016, the use of high-intensity statins increased from 25.0% to 49.2%, and the adherence increased from 58.7% to 70.5% (P < .001 for all trends). Patients with CHD were more likely to receive statins and high-intensity statins and adhere to medications than patients with ischemic stroke, TIA, or PAD despite similar observed treatment benefit. In 2016, 80.9% of patients with CHD used a statin vs 65.8% of patients with ischemic stroke or TIA and 37.5% of patients with PAD. Out-of-pocket cost per 30-day decreased from a median of $20 (interquartile range, $7.6-$31.9) in 2007 to $2 (interquartile range, $1.6-$10.0) in 2016 (P < .001) with the increasing use of generic statins (42.0% in 2007 vs 94.9% in 2016; P < .001). Major adverse cardiac events decreased from 8.9% in 2007 to 6.5% in 2016 (P < .001) whereas statin intolerance increased from 4.0% to 5.1% (P < .001). CONCLUSIONS AND RELEVANCE There have been modest improvements in the use, adherence, and cardiovascular outcomes over the past decade for statin therapy in patients with ASCVD, but a substantial and persistent treatment gap exists between patients with and without CHD, between men and women.
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Affiliation(s)
- Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Nilay D. Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
- OptumLabs, Cambridge, Massachusetts
| | - Bernard J. Gersh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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Kim YH, Her AY, Jeong MH, Kim BK, Hong SJ, Kim S, Ahn CM, Kim JS, Ko YG, Choi D, Hong MK, Jang Y. Beta-Blocker and Renin-Angiotensin System Inhibitor Combination Therapy in Patients with Acute Myocardial Infarction and Prediabetes or Diabetes Who Underwent Successful Implantation of Newer-Generation Drug-Eluting Stents: A Retrospective Observational Registry Study. J Clin Med 2020; 9:jcm9113447. [PMID: 33120966 PMCID: PMC7692957 DOI: 10.3390/jcm9113447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/22/2020] [Accepted: 10/23/2020] [Indexed: 12/11/2022] Open
Abstract
Long-term clinical outcomes in patients with acute myocardial infarction (AMI) and prediabetes or diabetes who received ß-blockers (BB) and renin–angiotensin system inhibitor (RASI) therapy after successful newer-generation drug-eluting stent (DES) implantation are limited. We compared the two-year clinical outcomes in such patients. A total of 9466 patients with AMI in the Korea AMI Registry were classified into six groups according to their glycemic status and presence or absence of BB + RASI therapy: normoglycemia and BB + RASI users (n = 2217) or nonusers (n = 243), prediabetes and BB + RASI users (n = 2601) or nonusers (n = 306), and diabetes and BB + RASI users (n = 3682) or nonusers (n = 417). The primary endpoint was major adverse cardiac events (MACEs) defined as all-cause death, recurrent myocardial infarction (Re-MI), or any repeat revascularization, and the secondary endpoint was the cumulative incidence of hospitalization for heart failure (HHF). In patients with BB + RASI, despite similar primary and secondary clinical points between the prediabetes and diabetes groups, the cumulative incidence of Re-MI (adjusted hazard ratio: 1.660; 95% confidence interval: 1.000–2.755; p = 0.020) was higher in the diabetes group than in the prediabetes group. In all three different glycemic groups, BB + RASI users showed reduced MACEs, cardiac death, and HHF compared to those of BB + RASI nonusers. In this retrospective observational registry study, BB + RASI therapy showed comparable clinical outcomes except for Re-MI between prediabetes and diabetes in patients with AMI during a two-year follow-up period.
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Affiliation(s)
- Yong Hoon Kim
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, Korea;
- Correspondence:
| | - Ae-Young Her
- Division of Cardiology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon 24341, Korea;
| | - Myung Ho Jeong
- Department of Cardiology, Cardiovascular Center, Chonnam National University Hospital, Gwangju 61469, Korea;
| | - Byeong-Keuk Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Sung-Jin Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Seunghwan Kim
- Division of Cardiology, Inje University College of Medicine, Haeundae Paik Hospital, Busan 48108, Korea;
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Young-Guk Ko
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Donghoon Choi
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Myeong-Ki Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul 03722, Korea; (B.-K.K.); (S.-J.H.); (C.-M.A.); (J.-S.K.); (Y.-G.K.); (D.C.); (M.-K.H.); (Y.J.)
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Kim HK, Ahn Y, Chang K, Jeong YH, Hahn JY, Choo EH, Kim MC, Kim HS, Kim W, Cho MC, Jang Y, Kim CJ, Jeong MH, Chae SC. 2020 Korean Society of Myocardial Infarction Expert Consensus Document on Pharmacotherapy for Acute Myocardial Infarction. Korean Circ J 2020; 50:845-866. [PMID: 32969206 PMCID: PMC7515755 DOI: 10.4070/kcj.2020.0196] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/01/2020] [Accepted: 07/29/2020] [Indexed: 02/07/2023] Open
Abstract
Clinical practice guidelines published by the European Society of Cardiology and the American College of Cardiology/American Heart Association summarize the available evidence and provide recommendations for health professionals to enable appropriate clinical decisions and improve clinical outcomes for patients with acute myocardial infarction (AMI). However, most current guidelines are based on studies in non-Asian populations in the pre-percutaneous coronary intervention (PCI) era. The Korea Acute Myocardial Infarction Registry is the first nationwide registry to document many aspects of AMI from baseline characteristics to treatment strategies. There are well-organized ongoing and published randomized control trials especially for antiplatelet therapy among Korean patients with AMI. Here, members of the Task Force of the Korean Society of Myocardial Infarction review recent published studies during the current PCI era, and have summarized the expert consensus for the pharmacotherapy of AMI.
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Affiliation(s)
- Hyun Kuk Kim
- Department of Internal Medicine, Chosun University College of Medicine, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Young Hoon Jeong
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Cardiovascular Center, Gyeongsang National University Changwon Hospital, Changwon, Korea
| | - Joo Yong Hahn
- Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Ho Choo
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyo Soo Kim
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Centre, Seoul National University Hospital, Seoul, Korea
| | - Weon Kim
- Division of Cardiovascular, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University, Seoul, Korea
| | - Myeong Chan Cho
- Department of Internal Medicine, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Yangsoo Jang
- Cardiology Division, Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Chong Jin Kim
- Cardiovascular Center, Kyung Hee University Hospital at Gangdong, Seoul, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea.
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
- School of Medicine, Kyungpook National University, Daegu, Korea.
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Mars K, Wallert J, Held C, Humphries S, Pingel R, Jernberg T, Olsson EMG, Hofmann R. Association between β-blocker dose and cardiovascular outcomes after myocardial infarction: insights from the SWEDEHEART registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:372-379. [PMID: 33620439 DOI: 10.1093/ehjacc/zuaa002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/15/2020] [Accepted: 07/24/2020] [Indexed: 12/17/2022]
Abstract
AIMS Dose-dependent effects of β-blockers on survival and cardiovascular outcomes after myocardial infarction (MI) are not well understood. We investigated the long-term risk of cardiovascular events in patients with different doses of β-blockers after MI. METHODS AND RESULTS This was a nationwide observational study linking morbidity, mortality, socioeconomic, and medication data from Swedish national registries. Between 2006 and 2015, 97 575 unique patients with first-time MI were included. In total, 33 126 (33.9%) patients were discharged with ≥50% of the target β-blocker dose and 64 449 (66.1%) patients with <50% of the target β-blocker dose used in previous randomized trials. The primary composite endpoint was re-infarction or all-cause death within 1 year from discharge. Multivariable adjusted 1-year follow-up estimates using mixed effects Cox regression [HR (95% CI)] showed that patients treated with ≥50% of the target dose had a similar risk of the composite endpoint [1.03 (0.99-1.08)] and a somewhat higher risk when stroke, atrial fibrillation, or heart failure hospitalization were added to the composite endpoint [1.08 (1.04-1.12)], compared with patients on <50% of the target β-blocker dose. Results remained similar up to 5 years of follow-up and consistent across relevant patient subgroups, including patients who developed heart failure during the index hospitalization. CONCLUSIONS In contrast to doses of β-blockers used in previous trials, ≥50% of the target β-blocker dose was not associated with superior cardiovascular outcomes up to 5 years as compared with <50% of the target dose. Contemporary randomized clinical trials are needed to clarify the optimal dose of β-blockers after MI.
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Affiliation(s)
- Katarina Mars
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 11883 Stockholm, Sweden
| | - John Wallert
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, 113 64 Stockholm, Sweden.,Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Claes Held
- Department of Medical Sciences, Cardiology, Uppsala University, 751 85 Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, 751 85 Uppsala, Sweden
| | - Sophia Humphries
- Department of Women's and Children's Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Ronnie Pingel
- Department of Statistics, Uppsala University, 751 20 Uppsala, Sweden
| | - Tomas Jernberg
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, 182 88 Stockholm, Sweden
| | - Erik M G Olsson
- Department of Women's and Children's Health, Uppsala University, 751 85 Uppsala, Sweden
| | - Robin Hofmann
- Department of Clinical Science and Education, Division of Cardiology, Karolinska Institutet, Södersjukhuset, 11883 Stockholm, Sweden
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Impacto pronóstico de la adherencia secundaria a betabloqueantes tras infarto de miocardio con elevación del segmento ST sin disfunción ventricular. Med Clin (Barc) 2020; 155:242-248. [DOI: 10.1016/j.medcli.2019.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 11/16/2019] [Accepted: 11/28/2019] [Indexed: 12/19/2022]
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De Luca L, Temporelli PL, Riccio C, Gonzini L, Marinacci L, Tartaglione SN, Costa P, Scherillo M, Senni M, Colivicchi F, Gulizia MM. Clinical outcomes, pharmacological treatment, and quality of life of patients with stable coronary artery diseases managed by cardiologists: 1-year results of the START study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2020; 5:334-342. [PMID: 30649303 DOI: 10.1093/ehjqcco/qcz002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 12/17/2018] [Accepted: 01/07/2019] [Indexed: 01/26/2023]
Abstract
AIMS We evaluated the 1-year clinical events, pharmacological management, and quality of life in a contemporary cohort of stable coronary artery disease (CAD) patients managed by cardiologists. METHODS AND RESULTS START (STable Coronary Artery Diseases RegisTry) was a prospective, observational, nationwide study that enrolled 5070 stable CAD patients over 3 months in 183 cardiology centres in Italy. At 1 year, 4790 (94.5%) patients had data on vital status. Death occurred in 107 (2.2%) patients and the cause of death was cardiovascular in 41 (38.3%) of cases. Among the 4775 patients with follow-up data on clinical events available, a hospitalization due to cardiovascular and non-cardiovascular causes occurred in 523 (11.0%) and in 231 (4.8%) of cases, respectively. Over 60% of patients reported as 'no problems' in all domains (61.4-84.5%) of the EuroQoL quality of life 5D-5L questionnaire. Among the 3239 patients with clinical visit/telephone interview at follow-up, in whom optimal medical therapy (OMT; aspirin or thienopyridine, β-blocker, and statin) was prescribed at enrolment, 2971 (91.7%) were still receiving OMT at follow-up. At multivariable analysis, only increasing age (odds ratio 0.98; 95% confidence interval 0.97-0.99; P = 0.04) resulted as independent negative predictor of OMT persistence at 1 year from enrolment. CONCLUSION In this large, contemporary registry, stable CAD patients managed by cardiologists presented a high rate of clinical events at 1 year. Nevertheless, the persistence to OMT and quality of life appeared reasonable.
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Affiliation(s)
- Leonardo De Luca
- Division of Cardiology, Interventional Cardiology Unit, S. Giovanni Evangelista Hospital, Via Parrozzani, 3 Tivoli, Rome, Italy
| | - Pier Luigi Temporelli
- Division of Cardiology, Istituti Clinici Scientifici Maugeri, IRCCS, Veruno, Via Revislate, 13, Novara, Italy
| | - Carmine Riccio
- Division of Cardiology, Azienda Ospedaliera Sant'Anna e San Sebastiano, Via F. Palasciano, Caserta, Italy
| | - Lucio Gonzini
- ANMCO Research Center, Via A. la Marmora, 36, Firenze, Italy
| | - Lina Marinacci
- Division of Cardiology, Presidio Ospedaliero Città di Castello, Via L. Angelini, 10, Perugia, Italy
| | - Sara Norma Tartaglione
- Division of Cardiology, Presidio Ospedaliero of Sanremo, Via Giovanni Borea, 56, Imperia, Italy
| | - Paolo Costa
- Division of Cardiology, G Di Maria Hospital, Avola, Vi G Mazzini, Siracusa, Italy
| | - Marino Scherillo
- Division of Cardiology, Azienda Ospedaliera G. Rummo, Via Pacevecchia, 53, Benevento, Italy
| | - Michele Senni
- Division of Cardiology, ASST Papa Giovanni XXIII, Piazza OMS, 1, Bergamo, Italy
| | - Furio Colivicchi
- Division of Cardiology, S. Filippo Neri Hospital, Via Giovanni Martinotti, 20, Rome, Italy
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Medication adherence and its determinants in patients after myocardial infarction. Sci Rep 2020; 10:12028. [PMID: 32694522 PMCID: PMC7374107 DOI: 10.1038/s41598-020-68915-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 06/22/2020] [Indexed: 11/08/2022] Open
Abstract
Non-adherence to prescribed medication is a serious limitation of long-term treatment in patients after myocardial infarction (MI), which can be associated with medical, social and economical consequences. Improvement of medication adherence has been shown to be a challenge for healthcare providers. The aim of this study was to evaluate changes in medication adherence and variability of adherence determinants during follow-up in patients after MI. A single-center, cohort observational study was conducted in 225 post-MI patients treated with primary coronary intervention (PCI) (27% women and 73% men) aged 30–91 years. Adherence was defined as availability of evaluated drugs within 1-year after discharge from hospital, based on completed prescriptions data obtained from the National Health Fund. The analysis of therapeutic plan realization (adherence to medication prescribed at discharge from hospital) embraced only reimbursed drugs: ACEIs (ramipril, perindopril), P2Y12 receptor inhibitors (clopidogrel) and statins (atorvastatin, simvastatin, rosuvastatin). Sufficient adherence was defined as ≥ 80%. During 1-year follow-up, adherence for all three drug classes was 64 ± 25%, with 67 ± 32% for ACEIs, 62 ± 34% for P2Y12 receptor inhibitor and 64 ± 32% for statins. A gradual decline in adherence was observed from 65% ± 26% in the first quarter of follow-up to 51% ± 34% in the last quarter of follow-up (p < 0.00001). Sufficient adherence for all drugs classes was found only in 29% of patients throughout the whole follow-up period (44% for ACEI, 36% for P2Y12 receptor inhibitor and 41% for statins). According to a multivariate analysis, age, prior CABG, level of education, place of residence, economic status and marital status were independent predictors of drug adherence. Whereas patients > 65 years and having a history of prior CABG more often had an insufficient adherence to drugs, married and hypertensive patients, city inhabitants and patients with higher education tended to have a sufficient drug adherence. Adherence to pharmacotherapy after myocardial infarction decreases over time in a similar manner for all pivotal groups of drugs prescribed after MI. A number of socioeconomic and clinical factors have been identified to affect medication adherence over time.
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Kasargod C, Devlin G, Lee M, White HD, Kerr AJ. Prescribing Performance Post-Acute Coronary Syndrome Using a Composite Medication Indicator: ANZACS-QI 24. Heart Lung Circ 2020; 29:824-834. [DOI: 10.1016/j.hlc.2019.05.179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/05/2018] [Accepted: 05/17/2019] [Indexed: 11/26/2022]
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Kristensen AMD, Bovin A, Zwisler AD, Cerquira C, Torp-Pedersen C, Bøtker HE, Gustafsson I, Veien KT, Thomsen KK, Olsen MH, Larsen ML, Nielsen OW, Hildebrandt P, Foghmar S, Jensen SE, Lange T, Sehested T, Jernberg T, Atar D, Ibanez B, Prescott E. Design and rationale of the Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction: study protocol for a randomized controlled trial. Trials 2020; 21:415. [PMID: 32446298 PMCID: PMC7245032 DOI: 10.1186/s13063-020-4214-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/27/2020] [Indexed: 11/10/2022] Open
Abstract
Background Treatment with beta-blockers is currently recommended after myocardial infarction (MI). The evidence relies on trials conducted decades ago before implementation of revascularization and contemporary medical therapy or in trials enrolling patients with heart failure or reduced left ventricular ejection fraction (LVEF ≤ 40%). Accordingly, the impact of beta-blockers on mortality and morbidity following acute MI in patients without reduced LVEF or heart failure is unclear. Methods/design The Danish trial of beta-blocker treatment after myocardial infarction without reduced ejection fraction (DANBLOCK) is a prospective, randomized, controlled, open-label, non-blinded endpoint clinical trial designed to evaluate the efficacy of beta-blocker treatment in post-MI patients in the absence of reduced LVEF or heart failure. We will randomize 3570 patients will be randomized within 14 days of index MI to beta-blocker or control for a minimum of 2 years. The primary endpoint is a composite of all-cause mortality, recurrent MI, acute decompensated heart failure, unstable angina pectoris, or stroke. The primary composite endpoint will be assessed through locally reported and adjudicated endpoints supplemented by linkage to the Danish national registers. A number of secondary endpoints will be investigated including patient reported outcomes and cardiovascular mortality. Data from similar ongoing trials in Norway and Sweden will be pooled to perform an individual patient data meta-analysis. Discussion DANBLOCK is a randomized clinical trial investigating the effect of long-term beta-blocker therapy after myocardial infarction in patients without heart failure and reduced LVEF. Results from the trial will add important scientific evidence to inform future clinical guidelines. Trial registration Clinicaltrials.gov, NCT03778554. Registered on 19 December 2018. European Clinical Trials Database, 2018-002699-42, registered on 28 September 2018.
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Affiliation(s)
| | - Ann Bovin
- Department of Cardiology, Sygehus Lillebælt, Vejle, Denmark
| | - Ann Dorthe Zwisler
- Danish Centre for Rehabilitation and Palliative Care, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | | | | | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | | | | | | | | | | | - Per Hildebrandt
- Department of Cardiology, Frederiksberg Heart Clinic, Copenhagen, Denmark
| | - Sussie Foghmar
- Department of Cardiology, Hvidovre-Amager Hospital, Hvidovre, Denmark
| | | | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Sehested
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Tomas Jernberg
- Department of Clinical Sciences, Division of Cardiology, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Borja Ibanez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC) & IIS- Fundación Jiménez Díaz & CIBERCV, Madrid, Spain
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
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Groenhof TKJ, Kofink D, Bots ML, Nathoe HM, Hoefer IE, Van Solinge WW, Lely AT, Asselbergs FW, Haitjema S. Low-Density Lipoprotein Cholesterol Target Attainment in Patients With Established Cardiovascular Disease: Analysis of Routine Care Data. JMIR Med Inform 2020; 8:e16400. [PMID: 32238333 PMCID: PMC7163416 DOI: 10.2196/16400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/20/2019] [Accepted: 12/31/2019] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Direct feedback on quality of care is one of the key features of a learning health care system (LHS), enabling health care professionals to improve upon the routine clinical care of their patients during practice. OBJECTIVE This study aimed to evaluate the potential of routine care data extracted from electronic health records (EHRs) in order to obtain reliable information on low-density lipoprotein cholesterol (LDL-c) management in cardiovascular disease (CVD) patients referred to a tertiary care center. METHODS We extracted all LDL-c measurements from the EHRs of patients with a history of CVD referred to the University Medical Center Utrecht. We assessed LDL-c target attainment at the time of referral and per year. In patients with multiple measurements, we analyzed LDL-c trajectories, truncated at 6 follow-up measurements. Lastly, we performed a logistic regression analysis to investigate factors associated with improvement of LDL-c at the next measurement. RESULTS Between February 2003 and December 2017, 250,749 LDL-c measurements were taken from 95,795 patients, of whom 23,932 had a history of CVD. At the time of referral, 51% of patients had not reached their LDL-c target. A large proportion of patients (55%) had no follow-up LDL-c measurements. Most of the patients with repeated measurements showed no change in LDL-c levels over time: the transition probability to remain in the same category was up to 0.84. Sequence clustering analysis showed more women (odds ratio 1.18, 95% CI 1.07-1.10) in the cluster with both most measurements off target and the most LDL-c measurements furthest from the target. Timing of drug prescription was difficult to determine from our data, limiting the interpretation of results regarding medication management. CONCLUSIONS Routine care data can be used to provide feedback on quality of care, such as LDL-c target attainment. These routine care data show high off-target prevalence and little change in LDL-c over time. Registrations of diagnosis; follow-up trajectory, including primary and secondary care; and medication use need to be improved in order to enhance usability of the EHR system for adequate feedback.
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Affiliation(s)
- T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Daniel Kofink
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Michiel L Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Hendrik M Nathoe
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Imo E Hoefer
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Wouter W Van Solinge
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - A Titia Lely
- Department of Obstetrics, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Folkert W Asselbergs
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.,Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, United Kingdom.,Health Data Research UK, Institute of Health Informatics, University College London, London, United Kingdom
| | - Saskia Haitjema
- Laboratory of Clinical Chemistry and Hematology, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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Solomon MD, Leong TK, Levin E, Rana JS, Jaffe MG, Sidney S, Sung SH, Lee C, DeMaria A, Go AS. Cumulative Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction. J Am Heart Assoc 2020; 9:e014415. [PMID: 32131689 PMCID: PMC7335507 DOI: 10.1161/jaha.119.014415] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 01/31/2020] [Indexed: 02/07/2023]
Abstract
Background The survival benefit associated with cumulative adherence to multiple clinical and lifestyle-related guideline recommendations for secondary prevention after acute myocardial infarction (AMI) is not well established. Methods and Results We examined adults with AMI (mean age 68 years; 64% men) surviving at least 30 (N=25 778) or 90 (N=24 200) days after discharge in a large integrated healthcare system in Northern California from 2008 to 2014. The association between all-cause death and adherence to 6 or 7 secondary prevention guideline recommendations including medical treatment (prescriptions for β-blockers, renin-angiotensin-aldosterone system inhibitors, lipid medications, and antiplatelet medications), risk factor control (blood pressure <140/90 mm Hg and low-density lipoprotein cholesterol <100 mg/dL), and lifestyle approaches (not smoking) at 30 or 90 days after AMI was evaluated with Cox proportional hazard models. To allow patients time to achieve low-density lipoprotein cholesterol <100 mg/dL, this metric was examined only among those alive 90 days after AMI. Overall guideline adherence was high (35% and 34% met 5 or 6 guidelines at 30 days; and 31% and 23% met 6 or 7 at 90 days, respectively). Greater guideline adherence was independently associated with lower mortality (hazard ratio, 0.57 [95% CI, 0.49-0.66] for those meeting 7 and hazard ratio, 0.69 [95% CI, 0.61-0.78] for those meeting 6 guidelines versus 0 to 3 guidelines in 90-day models, with similar results in the 30-day models), with significantly lower mortality per each additional guideline recommendation achieved. Conclusions In a large community-based population, cumulative adherence to guideline-recommended medical therapy, risk factor control, and lifestyle changes after AMI was associated with improved long-term survival. Full adherence was associated with the greatest survival benefit.
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Affiliation(s)
- Matthew D. Solomon
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
- Division of CardiologyKaiser Permanente Oakland Medical CenterOaklandCA
| | - Thomas K. Leong
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
| | - Eleanor Levin
- Division of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCA
| | - Jamal S. Rana
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
- Division of CardiologyKaiser Permanente Oakland Medical CenterOaklandCA
| | - Marc G. Jaffe
- Division of EndocrinologyKaiser
Permanente South San Francisco Medical CenterSan FranciscoCA
| | - Stephen Sidney
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
| | - Sue Hee Sung
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
| | - Catherine Lee
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
| | - Anthony DeMaria
- Division of CardiologyUniversity of California at San DiegoCA
| | - Alan S. Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCA
- Departments of Epidemiology, Biostatistics and MedicineUniversity of CaliforniaSan FranciscoCA
- Departments of Medicine, Health Research and PolicyStanford UniversityPalo AltoCA
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Zhou R, Gao J, Xiang C, Liu Z, Zhang Y, Zhang J, Yang H. Salvianolic acid A attenuated myocardial infarction–induced apoptosis and inflammation by activating Trx. Naunyn Schmiedebergs Arch Pharmacol 2019; 393:991-1002. [DOI: 10.1007/s00210-019-01766-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 11/08/2019] [Indexed: 01/30/2023]
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Shavadia JS, Zheng Y, Green JB, Armstrong PW, Westerhout CM, McGuire DK, Cornel JH, Holman RR, Peterson ED. Associations between β-blocker therapy and cardiovascular outcomes in patients with diabetes and established cardiovascular disease. Am Heart J 2019; 218:92-99. [PMID: 31715435 DOI: 10.1016/j.ahj.2019.09.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/16/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND The effects of β-blocker therapy in patients with type 2 diabetes (T2D) and established atherosclerotic cardiovascular disease (ASCVD) are unclear. We sought to evaluate associations between β-blocker use in T2D with ASCVD and cardiovascular (CV) outcomes. METHODS In patients with T2D and ASCVD enrolled in the Trial Evaluating Cardiovascular Outcomes with Sitagliptin (TECOS), an inverse probability of treatment-weighted Cox proportional hazards model was used to examine the association between baseline β-blocker therapy (at randomization) and the primary CV composite (defined as CV death, non-fatal myocardial infarction [MI], non-fatal stroke, or hospitalization for unstable angina), including in subgroups with prior MI and heart failure (HF); other outcomes evaluated included individual components of the primary composite, hospitalization for HF, and severe hypoglycemic events. RESULTS Of the 14,671 patients randomized, 9322 (64%) were on a β-blocker at baseline; these patients were more likely to have prior MI or HF. Over a median 3.0 (25th, 75th percentile: 2.2, 3.6) years, the risk of the primary CV composite was significantly higher with baseline β-blocker use versus no β-blocker use (4.5 vs. 3.4 events/100-patient years, adjusted hazard ratio [HR] 1.17, 95% confidence interval [CI] 1.05-1.29); no significant interaction was noted for patients with versus without prior MI or HF. Baseline β-blocker use was not associated with risks for severe hypoglycemic events (HR 1.14, 95% CI 0.88-1.48). CONCLUSIONS In this observational analysis of T2D and ASCVD, baseline β-blocker use was not associated with risks for severe hypoglycemia yet also was not associated with CV risk reduction over 3 years of follow-up, supporting a randomized examination of chronic β-blocker therapy in this patient population. (TECOS ClinicalTrials.gov number, NCT00790205).
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Affiliation(s)
- Jay S Shavadia
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC; Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatchewan, Canada; Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Jennifer B Green
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jan H Cornel
- Department of Cardiology, Northwest Clinics, Alkmaar, The Netherlands
| | - Rury R Holman
- Diabetes Trials Unit, University of Oxford, Oxford, UK
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Walsh CA, Cahir C, Tecklenborg S, Byrne C, Culbertson MA, Bennett KE. The association between medication non-adherence and adverse health outcomes in ageing populations: A systematic review and meta-analysis. Br J Clin Pharmacol 2019; 85:2464-2478. [PMID: 31486099 PMCID: PMC6848955 DOI: 10.1111/bcp.14075] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 07/03/2019] [Accepted: 07/12/2019] [Indexed: 01/16/2023] Open
Abstract
AIMS The aim of this systematic review and meta-analysis was to synthesise the evidence relating to medication non-adherence and its association with health outcomes in people aged ≥50 years. METHODS Seven databases were searched up to February 2019 for observational studies that measured medication (non-)adherence as a predictor of the following health outcomes in adults aged ≥50 years: healthcare utilisation (hospitalisation, emergency department visits, outpatient visits and general practitioner visits), mortality, adverse clinical events and quality of life. Screening and quality assessment using validated criteria were completed by 2 reviewers independently. Random effects models were used to generate pooled estimates of association using adjusted study results. The full methodological approach was published on PROSPERO (ID: CRD42017077264). RESULTS Sixty-six studies were identified for qualitative synthesis, with 11 of these studies eligible for meta-analyses. A meta-analysis including 3 studies measuring medication non-adherence in adults aged ≥55 years showed a significant association with all-cause hospitalisation (adjusted odds ratio 1.17, 95% confidence interval [CI] 1.12, 1.21). A meta-analysis including 2 studies showed that medication non-adherence was not significantly associated with an emergency department visit (adjusted odds ratio 1.05, 95% CI 0.90, 1.22). Good adherence was associated with a 21% reduction in long-term mortality risk in comparison to medication non-adherence (adjusted hazard ratio 0.79, 95% CI 0.63, 0.98). CONCLUSION Medication non-adherence may be significantly associated with all-cause hospitalisation and mortality in older people. Medication adherence should be monitored and addressed in this cohort to minimise hospitalisation, improve clinical outcomes and reduce healthcare costs.
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Affiliation(s)
- Caroline A. Walsh
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Caitriona Cahir
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Sarah Tecklenborg
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Catherine Byrne
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | - Kathleen E. Bennett
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
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Shavadia JS, Holmes DN, Thomas L, Peterson ED, Granger CB, Roe MT, Wang TY. Comparative Effectiveness of β-Blocker Use Beyond 3 Years After Myocardial Infarction and Long-Term Outcomes Among Elderly Patients. Circ Cardiovasc Qual Outcomes 2019; 12:e005103. [DOI: 10.1161/circoutcomes.118.005103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The benefit of β-blocker use beyond 3 years after a myocardial infarction (MI) has not been clearly determined.
Methods and Results:
Using data from the CRUSADE Registry (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines) linked with Medicare claims, we studied patients ≥65 years of age with MI, discharged on β-blocker therapy and alive 3 years later without a recurrent MI to evaluate β-blocker use and dose (none, <50%, and ≥50% of the recommended target) at 3 years. Using inverse probability of treatment weighting, we then examined the adjusted association between β-blocker use (and dose) at 3 years and the cardiovascular composite of all-cause mortality, hospitalization for recurrent MI, ischemic stroke, or heart failure over the subsequent 5 years. Of the 6893 patients ≥65 years age, β-blocker use at 3 years was 72.2% (n=4980); 43% (n=2162) of these were treated with ≥50% of the target β-blocker dose. β-blocker use was not associated with a significant difference on the composite outcome (52.4% versus 55.4%, adjusted hazard ratio, 0.95; 95% CI, 0.88–1.03;
P
=0.23). Neither low dose (<50% target dose) nor high dose (≥50% target dose) β-blocker use was associated with a significant difference in risk when compared with no β-blocker use. Results were also consistent in patients with and without heart failure or systolic dysfunction (
P
interaction =0.30).
Conclusions:
In this observational analysis, β-blocker use beyond 3 years post-MI, regardless of the dose achieved, was not associated with improved outcomes. The role of prolonged β-blocker use, particularly in older adults, needs further investigation.
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Affiliation(s)
- Jay S. Shavadia
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
- Division of Cardiology, Department of Medicine, University of Saskatchewan, Saskatoon, Canada (J.S.S.)
| | - DaJuanicia N. Holmes
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
| | - Eric D. Peterson
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
| | - Christopher B. Granger
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
| | - Matthew T. Roe
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
| | - Tracy Y. Wang
- Duke Clinical Research Institute, Durham, NC (J.S.S., D.N.H., L.T., E.D.P., C.B.G., M.T.R., T.Y.W.)
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e1082-e1143. [PMID: 30586774 PMCID: PMC7403606 DOI: 10.1161/cir.0000000000000625] [Citation(s) in RCA: 1176] [Impact Index Per Article: 235.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Scott M Grundy
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Neil J Stone
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Alison L Bailey
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Craig Beam
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Kim K Birtcher
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Roger S Blumenthal
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Lynne T Braun
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sarah de Ferranti
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Faiella-Tommasino
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel E Forman
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Ronald Goldberg
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Paul A Heidenreich
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Mark A Hlatky
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Daniel W Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Donald Lloyd-Jones
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Nuria Lopez-Pajares
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Chiadi E Ndumele
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carl E Orringer
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Carmen A Peralta
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph J Saseen
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Sidney C Smith
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Laurence Sperling
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Salim S Virani
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
| | - Joseph Yeboah
- ACC/AHA Representative. †AACVPR Representative. ‡ACC/AHA Task Force on Clinical Practice Guidelines Liaison. §Prevention Subcommittee Liaison. ‖PCNA Representative. ¶AAPA Representative. **AGS Representative. ††ADA Representative. ‡‡PM Representative. §§ACPM Representative. ‖‖NLA Representative. ¶¶APhA Representative. ***ASPC Representative. †††ABC Representative
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Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, Braun LT, de Ferranti S, Faiella-Tommasino J, Forman DE, Goldberg R, Heidenreich PA, Hlatky MA, Jones DW, Lloyd-Jones D, Lopez-Pajares N, Ndumele CE, Orringer CE, Peralta CA, Saseen JJ, Smith SC, Sperling L, Virani SS, Yeboah J. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol 2019; 73:e285-e350. [DOI: 10.1016/j.jacc.2018.11.003] [Citation(s) in RCA: 1113] [Impact Index Per Article: 222.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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45
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Peterson ED, Navar AM. "Sticky" Issues for Adherence in Secondary Prevention. J Am Coll Cardiol 2019; 70:1555-1557. [PMID: 28935031 DOI: 10.1016/j.jacc.2017.07.788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 07/29/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Eric D Peterson
- Duke University School of Medicine, Durham, North Carolina; Duke University Clinical Research Institute, Durham, North Carolina.
| | - Ann Marie Navar
- Duke University School of Medicine, Durham, North Carolina; Duke University Clinical Research Institute, Durham, North Carolina
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Nielsen RE, Kugathasan P, Straszek S, Jensen SE, Licht RW. Why are somatic diseases in bipolar disorder insufficiently treated? Int J Bipolar Disord 2019; 7:12. [PMID: 31055668 PMCID: PMC6500513 DOI: 10.1186/s40345-019-0147-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/23/2019] [Indexed: 12/27/2022] Open
Abstract
Background Somatic diseases, including cardiovascular, respiratory, and cancer diseases, are the main contributors to a shortened life expectancy of 10–20 years in patients with bipolar disorder as compared to the general population. In the general population an increase in survival has been observed over the last decades, primarily due to the advances in primary prophylaxis, medical treatment and progress in early detection and monitoring of somatic diseases. In this narrative review, we discuss the existing literature on treatment and outcomes of cardiovascular, respiratory, and cancer diseases in patients with bipolar disorder, and put this in the context of findings in studies on patients diagnosed with other severe mental disorders. Main body The existing literature suggests that patients with bipolar disorder receive fewer or delayed medical interventions, when admitted with severe somatic diseases, compared to those not diagnosed with bipolar disorder. Cardiovascular disease is the most investigated disease regarding outcomes in patients with severe mental illness, and novel findings indicate that the increased mortality following cardiac events in these patients can be reduced if they are intensively treated with secondary prophylactic cardiac intervention. Elderly patients diagnosed with mental disorders and cancer experience a delay in receiving specific cancer treatment. No studies have investigated treatment outcomes in patients with severe mental disease and respiratory diseases. Conclusion It is surprising and of major concern that patients with bipolar disorder have not benefitted from the significant improvement that has taken place over time over time of somatic treatments in general, especially in countries with equal and free access to healthcare services. Therefore, no matter whether this situation is a result of a negative attitude from health care providers to patients with mental illness, the result of the patient’s lack of awareness of their physical illness or the results of other factors, further attention including research on developing strategies for improving the management of somatic diseases in patients with bipolar disorder is needed.
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Affiliation(s)
- René Ernst Nielsen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. .,Department of Psychiatry, Aalborg University Hospital, Mølleparkvej 10, 9000, Aalborg, Denmark.
| | - Pirathiv Kugathasan
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Psychiatry, Aalborg University Hospital, Mølleparkvej 10, 9000, Aalborg, Denmark
| | - Sune Straszek
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Psychiatry, Aalborg University Hospital, Mølleparkvej 10, 9000, Aalborg, Denmark
| | - Svend Eggert Jensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Rasmus W Licht
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.,Department of Psychiatry, Aalborg University Hospital, Mølleparkvej 10, 9000, Aalborg, Denmark
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47
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Gacoń J, Przewlocki T, Podolec J, Badacz R, Pieniazek P, Ryniewicz W, Żmudka K, Kabłak-Ziembicka A. The role of serial carotid intima-media thickness assessment as a surrogate marker of atherosclerosis control in patients with recent myocardial infarction. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2019; 15:74-80. [PMID: 31043988 PMCID: PMC6488839 DOI: 10.5114/aic.2019.81705] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 12/09/2018] [Indexed: 06/09/2023] Open
Abstract
INTRODUCTION Despite percutaneous coronary intervention (PCI), patients after their first myocardial infarction (MI) are at high risk of ischemic event recurrence. Therefore, there is a need for objective markers of adequate atherosclerosis control, independent of prescribed pharmacotherapy and patients' compliance. Such a potential indicator of major adverse cerebral and coronary event (MACCE) risk might be change in carotid intima-media thickness (CIMT), which indicates atherosclerosis growth. AIM To evaluate the potential associations between CIMT changes and the incidence of MACCE and recurrent MI. MATERIAL AND METHODS The CIMT assessments at baseline and during 2 follow-up visits were performed in 215 patients admitted with MI, in whom PCI was performed for an index lesion, followed by best medical treatment. The incidences of MACCE (cardiovascular death, recurrent MI, ischemic stroke) and new onset angina were recorded prospectively. RESULTS The MACCE were recorded in 65 (30.2%) patients and angina due to coronary lesion progression (CLP) in 27 (12.5%) patients. Although initial CIMT values were similar in patients who suffered MACCE vs. MACCE-free patients (1.43 ±0.40 vs. 1.45 ±0.44 mm; p = 0.486), patients in whom MACCE occurred had greater annual CIMT growth as assessed at the first (0.024 ±0.12 vs. 0.009 ±0.16 mm/year; p < 0.001) and subsequent follow-up visit (0.050 ±0.1 vs. 0.001 ±0.1 mm/year; p < 0.001), in mean 36.5 ±29.3 and 53.3 ±37.1 months, respectively. An optimal cut-off value for annual CIMT change of > 0.003 mm/year (sensitivity: 84.5%, specificity: 49.3%) for MI plus CLP (AUC = 0.673) occurred an independent indicator of MACCE (HR = 3.00; 95% CI: 1.496-6.016), recurrent MI (HR = 4.59, 95% CI: 1.591-13.217), and MI plus CLP (HR = 3.50, 95% CI: 1.759-6.964). CONCLUSIONS Annual CIMT change might be a potentially valuable marker of atherosclerosis response to post-MI treatment.
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Affiliation(s)
- Jacek Gacoń
- Department of Invasive Cardiology, E. Szczeklik’s Hospital, Tarnow, Poland
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Tadeusz Przewlocki
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Jakub Podolec
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Rafal Badacz
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Piotr Pieniazek
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Wojciech Ryniewicz
- Department of Dental Prosthetics, Institute of Dentistry, Jagiellonian University School of Medicine, Krakow, Poland
| | - Krzysztof Żmudka
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
| | - Anna Kabłak-Ziembicka
- Department of Interventional Cardiology, Jagiellonian University School of Medicine, the John Paul II Hospital, Krakow, Poland
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48
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Dahl Aarvik M, Sandven I, Dondo TB, Gale CP, Ruddox V, Munkhaugen J, Atar D, Otterstad JE. Effect of oral β-blocker treatment on mortality in contemporary post-myocardial infarction patients: a systematic review and meta-analysis. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2019; 5:12-20. [PMID: 30192930 PMCID: PMC6321955 DOI: 10.1093/ehjcvp/pvy034] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 09/02/2018] [Indexed: 12/28/2022]
Abstract
Aims Guidelines concerning β-blocker treatment following acute myocardial infarction (AMI) are based on studies undertaken before the implementation of reperfusion and secondary prevention therapies. We aimed to estimate the effect of oral β-blockers on mortality in contemporary post-AMI patients with low prevalence of heart failure and/or reduced left ventricular ejection fraction. Methods and results A random effects model was used to synthetize results of 16 observational studies published between 1 January 2000 and 30 October 2017. Publication bias was evaluated, and heterogeneity between studies examined by subgroup and random effects meta-regression analyses considering patient-related and study-level variables. The pooled estimate showed that β-blocker treatment [among 164 408 (86.8%) patients, with median follow-up time of 2.7 years] was associated with a 26% reduction in all-cause mortality [rate ratio (RR) 0.74, 95% confidence interval (CI) 0.64–0.85] with moderate heterogeneity (I2 = 67.4%). The patient-level variable mean age of the cohort explained 31.5% of between study heterogeneity. There was presence of publication bias, or small study effect, and when controlling for bias by the trim and fill simulation method, the effect disappeared (adjusted RR 0.90, 95% CI 0.77–1.04). Also, small study effect was demonstrated by a cumulative meta-analysis starting with the largest study showing no effect, with increasing effect as the smaller studies were accumulated. Conclusion Evidence from this study suggests that there is no association between β-blockers and all-cause mortality. A possible beneficial effect in AMI survivors needs to be tested by large randomized clinical trials.
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Affiliation(s)
- Magnus Dahl Aarvik
- Institute of Clinical Sciences, University of Oslo, Sognsvannsveien 9, Oslo, Norway
| | - Irene Sandven
- Oslo Centre for Biostatistics and Epidemiology, Oslo University Hospital, Sogn Arena, Nydalen, Oslo, Norway
| | - Tatendashe B Dondo
- Leeds Institute of Cardiovascular and Metabolic Medicince, Clarendon Way, University of Leeds, Leeds, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicince, Clarendon Way, University of Leeds, Leeds, UK
| | - Vidar Ruddox
- Department of Cardiology, Vestfold Hospital Trust, N-3103 Toensberg, Norway
| | - John Munkhaugen
- Department of Medicine, Drammen Hospital, Vestre Viken Trust, Wergelandsgate 10, Drammen, Norway
| | - Dan Atar
- Institute of Clinical Sciences, University of Oslo, Sognsvannsveien 9, Oslo, Norway.,Department of Cardiology B, Oslo University Hospital, Ullevaal, Kirkeveien 166, Oslo, Norway
| | - Jan Erik Otterstad
- Department of Cardiology, Vestfold Hospital Trust, N-3103 Toensberg, Norway
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49
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Munkhaugen J, Ruddox V, Halvorsen S, Dammen T, Fagerland MW, Hernæs KH, Vethe NT, Prescott E, Jensen SE, Rødevand O, Jortveit J, Bendz B, Schirmer H, Køber L, Bøtker HE, Larsen AI, Vikenes K, Steigen T, Wiseth R, Pedersen T, Edvardsen T, Otterstad JE, Atar D. BEtablocker Treatment After acute Myocardial Infarction in revascularized patients without reduced left ventricular ejection fraction (BETAMI): Rationale and design of a prospective, randomized, open, blinded end point study. Am Heart J 2019; 208:37-46. [PMID: 30530121 DOI: 10.1016/j.ahj.2018.10.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 10/20/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Current guidelines on the use of β-blockers in post-acute myocardial infarction (MI) patients without reduced left ventricular ejection fraction (LVEF) are based on studies before the implementation of modern reperfusion and secondary prevention therapies. It remains unknown whether β-blockers will reduce mortality and recurrent MI in contemporary revascularized post-MI patients without reduced LVEF. DESIGN BETAMI is a prospective, randomized, open, blinded end point multicenter study in 10,000 MI patients designed to test the superiority of oral β-blocker therapy compared to no β-blocker therapy. Patients with LVEF ≥40% following treatment with percutaneous coronary intervention or thrombolysis and/or no clinical signs of heart failure are eligible to participate. The primary end point is a composite of all-cause mortality or recurrent MI obtained from national registries over a mean follow-up period of 3 years. Safety end points include rates of nonfatal MI, all-cause mortality, ventricular arrhythmias, and hospitalizations for heart failure obtained from hospital medical records 30 days after randomization, and from national registries after 6 and 18 months. Key secondary end points include recurrent MI, heart failure, cardiovascular and all-cause mortality, and clinical outcomes linked to β-blocker therapy including drug adherence, adverse effects, cardiovascular risk factors, psychosocial factors, and health economy. Statistical analyses will be conducted according to the intention-to-treat principle. A prespecified per-protocol analysis (patients truly on β-blockers or not) will also be conducted. CONCLUSIONS The results from the BETAMI trial may have the potential of changing current clinical practice for treatment with β-blockers following MI in patients without reduced LVEF. EudraCT number 2018-000590-75.
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Affiliation(s)
- John Munkhaugen
- Department of Medicine, Drammen Hospital, Vestre Viken Trust, Drammen, Norway; Department of Behavioural Science in Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Vidar Ruddox
- Department for Cardiology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital, Ullevaal and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Toril Dammen
- Department of Behavioural Science in Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Morten W Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Kjersti H Hernæs
- Clinical Trial Unit Health economics, Oslo University Hospital, Oslo, Norway
| | - Nils Tore Vethe
- Department of Pharmacology, Oslo University Hospital, Oslo, Norway
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | | | - Olaf Rødevand
- LHL Department of Cardiology, LHL Hospital Gardermoen, Gardermoen, Norway
| | - Jarle Jortveit
- Department of Cardiology, Sørlandet Hospital Arendal, Arendal, Norway
| | - Bjørn Bendz
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Henrik Schirmer
- Department of Cardiology, Akershus University Hospital AHUS, Lørenskog, Norway
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Hans Erik Bøtker
- Department of Cardiology, Aarhus University Hospital Skejby, Skejby, Denmark
| | - Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Terje Steigen
- Department of Cardiology, University Hospital of North Norway and the Arctic University of Norway, Tromsø, Norway
| | - Rune Wiseth
- Clinic of Cardiology, St Olavs University Hospital, Trondheim, Norway
| | - Terje Pedersen
- Oslo University Hospital, Ullevaal and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Jan Erik Otterstad
- Department of Behavioural Science in Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital, Ullevaal and Faculty of Medicine, University of Oslo, Oslo, Norway
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50
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Fried TR, Mecca MC. Medication Appropriateness in Vulnerable Older Adults: Healthy Skepticism of Appropriate Polypharmacy. J Am Geriatr Soc 2019; 67:1123-1127. [PMID: 30697698 DOI: 10.1111/jgs.15798] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/26/2018] [Accepted: 12/31/2018] [Indexed: 11/29/2022]
Abstract
Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of "inappropriate" vs "appropriate" polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.
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Affiliation(s)
- Terri R Fried
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Marcia C Mecca
- VA Connecticut Healthcare System, Clinical Epidemiology Research Center and Geriatrics & Extended Care, West Haven, Connecticut.,Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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