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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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Holt A, Blanche P, Zareini B, Rajan D, El-Sheikh M, Schjerning AM, Schou M, Torp-Pedersen C, McGettigan P, Gislason GH, Lamberts M. Effect of long-term beta-blocker treatment following myocardial infarction among stable, optimally treated patients without heart failure in the reperfusion era: a Danish, nationwide cohort study. Eur Heart J 2021; 42:907-914. [PMID: 33428707 DOI: 10.1093/eurheartj/ehaa1058] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/14/2020] [Accepted: 12/10/2020] [Indexed: 11/13/2022] Open
Abstract
AIMS We aimed to investigate the long-term cardio-protective effect associated with beta-blocker (BB) treatment in stable, optimally treated myocardial infarction (MI) patients without heart failure (HF). METHODS AND RESULTS Using nationwide registries, we included patients with first-time MI undergoing coronary angiography (CAG) or percutaneous coronary intervention (PCI) during admission and treated with both acetyl-salicylic acid and statins post-discharge between 2003 and 2018. Patients with prior history of MI, prior BB use, or any alternative indication or contraindication for BB treatment were excluded. Follow-up began 3 months following discharge in patients alive, free of cardiovascular (CV) events or procedures. Primary outcomes were CV death, recurrent MI, and a composite outcome of CV events. We used adjusted logistic regression and reported standardized absolute risks and differences (ARD) 3 years after MI. Overall, 30 177 stable, optimally treated MI patients were included (58% acute PCI, 26% sub-acute PCI, 16% CAG without intervention). At baseline, 82% of patients were on BB treatment (median age 61 years, 75% male) and 18% were not (median age 62 years, 68% male). BB treatment was associated with a similar risk of CV death, recurrent MI, and the composite outcome of CV events compared with no BB treatment [ARD (95% confidence intervals)] correspondingly; 0.1% (-0.3% to 0.5%), 0.2% (-0.7% to 1.2%), and 1.2% (-0.2% to 2.7%). CONCLUSIONS In this nationwide cohort study of stable, optimally treated MI patients without HF, we found no long-term effect of BB treatment on CV prognosis following the patients from 3 months to 3 years after MI admission.
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Affiliation(s)
- Anders Holt
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
| | - Paul Blanche
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark.,Department of Biostatistics, Copenhagen University, Øster Farimagsgade 5, DK-1014 Copenhagen, Denmark
| | - Bochra Zareini
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
| | - Deepthi Rajan
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
| | - Mohammed El-Sheikh
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
| | - Anne-Marie Schjerning
- Department of Cardiology, Zealand University Hospital, Sygehusvej 10, DK-4000 Roskilde, Denmark
| | - Morten Schou
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, DK-9100 Aalborg, Denmark.,Department of Clinical investigation and Cardiology, Nordsjællands Hospital, Dyrehavevej 29, DK-3400 Hillerød, Denmark
| | - Patricia McGettigan
- Department of Clinical Pharmacology, William Harvey Research Institute, Charterhouse Square Barts and the London School of Medicine and Dentistry Queen Mary University of London, London EC1M 6BQ, UK
| | - Gunnar H Gislason
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark.,Department of Research, Danish Heart Foundation, Vognmagergade 7, 3. sal DK-1120 Copenhagen, Denmark
| | - Morten Lamberts
- Research Division, Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte Hospitalsvej 6, Postbox 635, DK-2900 Copenhagen, Denmark
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Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Lueckmann SL, Mlinarić M, Richter M. [Social inequalities in healthcare provision for patients with coronary heart disease: Results from the GEDA (German Health Update) study 2014/2015]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2021; 160:48-54. [PMID: 33451924 DOI: 10.1016/j.zefq.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/26/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Little is known about social inequalities in outpatient long-term care of coronary heart disease (CHD) in Germany. METHODS Regression analyses are based on the responses of women and men who participated in the national cross-sectional study "German Health update" (GEDA) 2014/2015 and had self-reported CHD (N=920). Outpatient healthcare of CHD was analysed on the basis of the self-reported administration of antihypertensive and cholesterol-lowering drugs, and the frequency of general practitioner (GP) contacts. RESULTS On average, respondents visited their GP 7.5 times a year (mean). 46 % did not receive guideline-consistent treatment, i. e. both antihypertensive and cholesterol-lowering drugs. Respondents of lower social status consulted their GP more frequently (approx. two visits per year) than those of higher social status (AME: 1.94; 95% CI 0.56 to 3.31). Regarding treatment with antihypertensive and cholesterol-lowering drugs, there were no significant differences for either gender or social status. Nevertheless, the probability that respondents with increased levels of blood lipids or cholesterol took only one or none of the two medications recommended for long-term treatment of CHD was reduced by 54 percentage points (AME: -0,54; 95% CI -0,61 to -0,48). DISCUSSION There are no social inequalities in the treatment of CHD patients with antihypertensive and cholesterol-lowering drugs, but inequalities exist in the frequency of visits to the GP who is more often consulted by the more socially disadvantaged patients. CONCLUSION With about 7.5 consultations per year, CHD patients visit their general practitioner more often than average, but in about half of these patients the medication supply is less than optimal. This may indicate a deficit in the medical treatment of CHD that cannot be explained by social inequalities. A possible starting point for improving healthcare, especially for patients without other risk factors, is to focus more strongly on a guideline-based approach to prescribing medication for CHD patients.
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Affiliation(s)
- Sara L Lueckmann
- Institut für Medizinische Soziologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland.
| | - Martin Mlinarić
- Institut für Medizinische Soziologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Matthias Richter
- Institut für Medizinische Soziologie, Medizinische Fakultät, Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
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Lee PH, Park GM, Han S, Kim YG, Lee JY, Roh JH, Lee JH, Kim YH, Lee SW. Beta-blockers provide a differential survival benefit in patients with coronary artery disease undergoing contemporary post-percutaneous coronary intervention management. Sci Rep 2020; 10:22121. [PMID: 33335231 PMCID: PMC7746699 DOI: 10.1038/s41598-020-79214-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 12/07/2020] [Indexed: 12/28/2022] Open
Abstract
Beta-adrenergic receptor blockers are used in patients with coronary artery disease (CAD) to reduce the harmful effects of excessive adrenergic activation on the heart. However, there is limited evidence regarding the benefit of beta-blockers in the context of contemporary management following percutaneous coronary intervention (PCI). We used the nationwide South Korea National Health Insurance database to identify 87,980 patients with a diagnosis of either acute myocardial infarction (AMI; n = 38,246) or angina pectoris (n = 49,734) who underwent PCI between 2013 and 2017, and survived to be discharged from hospital. Beta-blockers were used in a higher proportion of patients with AMI (80.6%) than those with angina (58.9%). Over a median follow-up of 2.2 years (interquartile range 1.2-3.3 years) with the propensity-score matching analysis, the mortality risk was significantly lower in patients treated with a beta-blocker in the AMI group (HR: 0.78; 95% CI 0.69-0.87; p < 0.001). However, the mortality risk was comparable regardless of beta-blocker use (HR: 1.07; 95% CI 0.98-1.16; p = 0.10) in the angina group. The survival benefit associated with beta-blocker therapy was most significant in the first year after the AMI event.
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Affiliation(s)
- Pil Hyung Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gyung-Min Park
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Korea.
| | - Seungbong Han
- Department of Applied Statistics, Gachon University, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si, Gyeonggi-do, 13120, Korea.
| | - Yong-Giun Kim
- Department of Cardiology, Ulsan University Hospital, University of Ulsan College of Medicine, 877 Bangeojinsunhwando-ro, Dong-gu, Ulsan, 44033, Korea
| | - Jong-Young Lee
- Department of Cardiology, Kangbuk Samsung Hospital, School of Medicine, Sungkyunkwan University, Seoul, Korea
| | - Jae-Hyung Roh
- Department of Cardiology, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Jae-Hwan Lee
- Department of Cardiology, Chungnam National University Sejong Hospital, Sejong, Korea
| | - Young-Hak Kim
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Whan Lee
- Department of Cardiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Freier C, Heintze C, Herrmann WJ. Prescribing and medical non-adherence after myocardial infarction: qualitative interviews with general practitioners in Germany. BMC FAMILY PRACTICE 2020; 21:81. [PMID: 32384915 PMCID: PMC7210678 DOI: 10.1186/s12875-020-01145-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 04/15/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND An increasing prevalence of having survived a myocardial infarction increases the importance of medical secondary prevention. Although preventive medication reduces mortality, prescribing and adherence are known to be frequently insufficient. General practitioners are the most important prescriber. However, their perspective on prescribing and medical non-adherence following myocardial infarction has not yet been explored. Thus, the aim of this study was to explore the general practitioners' perspective on long-term care after myocardial infarction focussing on medical prevention. METHODS In this qualitative interview study we conducted episodic interviews with sixteen general practitioners from rural and urban surgeries in Germany. Framework analysis with focus on general practitioners' prescribing and patients' non-adherence was performed. RESULTS Almost all general practitioners reported following guidelines for myocardial infarction aftercare and prescribing the medication that was initiated in the hospital; however, they described deviating from guidelines because of drugs' side effects or patients' intolerances. Some questioned the benefits of medical secondary prevention for the oldest of patients. General practitioners perceived good adherence among their patients who had had an MI while they regarded their methods for assessing medical non-adherence as limited. They perceived diverse reasons for non-adherence, particularly side effects, patients' freedom from symptoms and patients' indifference to health. They attributed mainly negative characteristics, like lack of knowledge and understanding, to non-adherent patients. These characteristics contribute to the difficulty of convincing these patients to take medications as prescribed. General practitioners improved adherence by preventing side effects, explaining the medication's necessity, facilitating intake and involving patients in decision-making. However, about half of the general practitioners reported threatening their patients with negative consequences of non-adherence. CONCLUSIONS General practitioners should be aware that discharge medication can be insufficient and thus, should always check hospital recommendations for accordance with guideline recommendations. Improving physicians' communication skills and informing and motivating patients in an adequate manner, for example in simple language, should be an important goal in the hospital and the general practitioner setting. General practitioners should assess patients' motivations through motivational interviewing, which no general practitioner mentioned during the interviews, and talk with them about adherence and long-term treatment goals regularly.
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Affiliation(s)
- Christian Freier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany
| | - Wolfram J Herrmann
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institute of General Practice, Charitéplatz 1, 10117, Berlin, Germany.,Münster School of Health, FH Münster - University of Applied Sciences, Leonardo Campus 8, 48149, Münster, Germany
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Association between Adherence to Guideline-Recommended Preventive Medications and In-Hospital Mortality among Non-Reperfused ST-Elevation Myocardial Infarction Patients Admitted to a Tertiary Care Academic Center in a Developing Country. Glob Heart 2020; 15:8. [PMID: 32489781 PMCID: PMC7218801 DOI: 10.5334/gh.394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background and aims: Acute ST-elevation myocardial infarction (STEMI) is a potentially fatal presentation of coronary artery disease (CAD). Evidence of the impact of acute pharmacological interventions in non-reperfused STEMI patients on subsequent events is limited. We aimed to assess the association between adherence to guideline-recommended preventive medications and in-hospital mortality among this high-risk patient population. Methods: We conducted a cohort study using data obtained from the Jakarta Acute Coronary Syndrome (JAC) Registry database from a tertiary care academic hospital in Indonesia. We included 1132 of 2694 patients with STEMI recorded between 1 January 2014 and 31 December 2016 who did not undergo acute reperfusion therapy. Adherence to guideline-recommended preventive medications was defined as the combined administration of aspirin, clopidogrel, anticoagulants and statins after hospital admission. The main outcome measure was in-hospital mortality. Results: Overall, 778 of 1132 patients (69%) received the combination of preventive medications. The guideline non-adherent group had significantly more patients with earlier onset of STEMI, higher Killip class and thrombolysis in myocardial infarction (TIMI) score. After adjustments for measured characteristics using logistic regression modeling, exposure to the combination of preventive therapies was associated with a statistically significant lower risk for in-hospital mortality (adjusted odds ratio: 0.46, 95% confidence interval: 0.30–0.70). Conclusions: Adherence to guideline-recommended preventive medications was associated with lower risk of in-hospital mortality in non-reperfused STEMI patients. The predictors of not receiving these medications need to be confirmed in future research.
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Ulrich R, Pischon T, Robra BP, Freier C, Heintze C, Herrmann WJ. Health care utilisation and medication one year after myocardial infarction in Germany - a claims data analysis. Int J Cardiol 2020; 300:20-26. [PMID: 31371116 DOI: 10.1016/j.ijcard.2019.07.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 07/10/2019] [Accepted: 07/15/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND After myocardial infarction, guidelines recommend pharmaceutical treatment with a combination of five different types of drugs for prevention in patients. However, studies from different countries have shown that this goal is not achieved in many patients. The aim of this study was to assess both healthcare and prescribed pharmaceutical treatment in the fourth quarter after index myocardial infarction. METHODS We conducted a claims data analysis with the data of patients who had had a myocardial infarction in the years 2013 or 2014, using information from the largest German health insurance fund ('AOK'). We analysed contact with physicians, hospital care and actual prescriptions for medication recommended in international guidelines, referring to beta-blockers, ACE inhibitors or angiotensin II receptor blockers, P2Y12-antiplatelet agents, acetylsalicylic acid and statins, one year after myocardial infarction. Analysis was stratified by age and sex, compared between patient groups and over time. RESULTS We identified 2352 patients who had survived myocardial infarction. Some 96.9% of these participants had at least one contact with their general practitioner (GP) one year after myocardial infarction, 22.8% contacted a cardiologist and 19.7% were hospitalised. Prescription rates range from 37.8% for acetylsalicylic acid to 70.4% for ACE inhibitors. However, only 24.1% received statins, beta-blockers, ACE inhibitors and an antiplatelet drug simultaneously. Prescription of recommended drugs after myocardial infarction decreased steadily over time. DISCUSSION Long-term medical prevention after myocardial infarction is improvable. GPs should take care of the pharmaceutical prevention after myocardial infarction as they are the physicians seen most intensively in this period.
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Affiliation(s)
| | | | | | | | | | - Wolfram J Herrmann
- Charité-Universitätsmedizin Berlin, Germany; Hochschule Furtwangen University, Furtwangen, Germany.
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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Ahrens I, Averkov O, Zúñiga EC, Fong AYY, Alhabib KF, Halvorsen S, Abdul Kader MABSK, Sanz‐Ruiz R, Welsh R, Yan H, Aylward P. Invasive and antiplatelet treatment of patients with non-ST-segment elevation myocardial infarction: Understanding and addressing the global risk-treatment paradox. Clin Cardiol 2019; 42:1028-1040. [PMID: 31317575 PMCID: PMC6788484 DOI: 10.1002/clc.23232] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 06/27/2019] [Accepted: 07/06/2019] [Indexed: 12/14/2022] Open
Abstract
Clinical guidelines for the treatment of patients with non-ST-segment elevation myocardial infarction (NSTEMI) recommend an invasive strategy with cardiac catheterization, revascularization when clinically appropriate, and initiation of dual antiplatelet therapy regardless of whether the patient receives revascularization. However, although patients with NSTEMI have a higher long-term mortality risk than patients with ST-segment elevation myocardial infarction (STEMI), they are often treated less aggressively; with those who have the highest ischemic risk often receiving the least aggressive treatment (the "treatment-risk paradox"). Here, using evidence gathered from across the world, we examine some reasons behind the suboptimal treatment of patients with NSTEMI, and recommend approaches to address this issue in order to improve the standard of healthcare for this group of patients. The challenges for the treatment of patients with NSTEMI can be categorized into four "P" factors that contribute to poor clinical outcomes: patient characteristics being heterogeneous; physicians underestimating the high ischemic risk compared with bleeding risk; procedure availability; and policy within the healthcare system. To address these challenges, potential approaches include: developing guidelines and protocols that incorporate rigorous definitions of NSTEMI; risk assessment and integrated quality assessment measures; providing education to physicians on the management of long-term cardiovascular risk in patients with NSTEMI; and making stents and antiplatelet therapies more accessible to patients.
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Affiliation(s)
- Ingo Ahrens
- Augustinerinnen Hospital, Academic Teaching HospitalUniversity of CologneCologneGermany
| | - Oleg Averkov
- Pirogov Russian National Research Medical UniversityMoscowRussia
| | | | - Alan Y. Y. Fong
- Department of CardiologySarawak Heart CentreKota SamarahanMalaysia
| | - Khalid F. Alhabib
- Department of Cardiac Sciences, King Fahad Cardiac CentreCollege of Medicine, King Saud UniversityRiyadhSaudi Arabia
| | | | | | | | - Robert Welsh
- Mazankowski Alberta Heart Institute and University of AlbertaEdmontonAlbertaCanada
| | | | - Philip Aylward
- South Australian Health and Medical Research InstituteFlinders University and Medical CentreAdelaideAustralia
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Lee CK, Lai CL, Lee MH, Su FY, Yeh TS, Cheng LY, Hsieh MY, Wu YW, Liu YB, Wu CC. Reinforcement of patient education improved physicians' adherence to guideline-recommended medical therapy after acute coronary syndrome. PLoS One 2019; 14:e0217444. [PMID: 31170175 PMCID: PMC6553689 DOI: 10.1371/journal.pone.0217444] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 05/10/2019] [Indexed: 11/18/2022] Open
Abstract
Background Prescription of guideline-recommended medicines after acute coronary syndrome (ACS) has been suboptimal. Tools for improving the use of medications have been developed, but they mainly targeted physicians. Objective We evaluated the effects of reinforcement of patient and family education on the usage of guideline-recommended secondary prevention medications. Methods This was a retrospective analysis of a prospectively collected registry of patients with ACS who were admitted to a regional teaching hospital in Taiwan between February 2015 and April 2017. The control group included 76 patients discharged before implementing the electronic-based patient and family education (PFE) system. The intervention group included 206 patients discharged after implementation. The primary outcome was the prescription rate of all four guideline-recommended drugs. Predictors of adherence were also evaluated. Results The study cohort included 282 ACS patients (188 men and 94 women) with a mean age of 68.5 years (standard deviation, 14.2). The intervention group patients were younger, had more family history of premature cardiovascular disease, more dyslipidemia, and underwent more reperfusion therapy. The intervention group was prescribed more guideline-recommended drugs than the control group: dual antiplatelet agents, 79.61% vs. 47.37% (p<0.001); statins, 74.76% vs. 34.21% (p<0.001); beta-blockers, 81.07% vs. 46.05% (p<0.001); angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, 62.62% vs. 38.16% (p<0.001); and a combination of all four medications, 39.32% vs. 14.47% (p<0.001). After adjusting baseline variables, the PFE system remained a significant contributor to adherence to these drugs use (P = 0.02). Conclusions Reinforcement of patient education was associated with significant improvements in physicians’ adherence to guideline-recommended medical therapy after acute coronary syndrome.
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Affiliation(s)
- Chih-Kuo Lee
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ming-Hsien Lee
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - Fang-Ying Su
- Biotechology R&D Center, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Tzu-Shan Yeh
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - Li-Ying Cheng
- Department of Nursing, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan
| | - Mu-Yang Hsieh
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail: (MYH); (CCW)
| | - Yen-Wen Wu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Cardiology, Cardiovascular Medical Center, and Department of Nuclear Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
- National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yen-Bin Liu
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Cheng Wu
- Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
- Institute of Biomedical Engineering, National Tsing-Hwa University, Hsinchu, Taiwan
- * E-mail: (MYH); (CCW)
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Ma TT, Wong ICK, Man KKC, Chen Y, Crake T, Ozkor MA, Ding LQ, Wang ZX, Zhang L, Wei L. Effect of evidence-based therapy for secondary prevention of cardiovascular disease: Systematic review and meta-analysis. PLoS One 2019; 14:e0210988. [PMID: 30657781 PMCID: PMC6338367 DOI: 10.1371/journal.pone.0210988] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/05/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The combination pharmacotherapy of antiplatelet agents, lipid-modifiers, ACE inhibitors/ARBs and beta-blockers are recommended by international guidelines. However, data on effectiveness of the evidence-based combination pharmacotherapy (EBCP) is limited. OBJECTIVES To determine the effect of EBCP on mortality and Cardiovascular events in patients with Coronary Heart Disease (CHD) or cerebrovascular disease. METHODS Publications in EMBASE and Medline up to October 2018 were searched for cohort and case-control studies on EBCP for the secondary prevention of cardiovascular disease. The main outcomes were all-cause mortality and major cardiovascular events. Meta-analyses were performed based on random effects models. RESULTS 21 studies were included. Comparing EBCP to either monotherapy or no therapy, the pooled risk ratios were 0.60 (95% confidence interval 0.55 to 0.66) for all-cause mortality, 0.70 (0.62 to 0.79) for vascular mortality, 0.73 (0.64 to 0.83) for myocardial infarction and 0.79 (0.68 to 0.91) for cerebrovascular events. Optimal EBCP (all 4 classes of drug prescribed) had a risk ratio for all-cause mortality of 0.50 (0.40 to 0.64). This benefit became more dilute as the number of different classes of drug comprising EBCP was decreased-for 3 classes of drug prescribed the risk ratio was 0.58 (0.49 to 0.69) and for 2 classes, the risk ratio was 0.67 (0.60 to 0.76). CONCLUSIONS EBCP reduces the risk of all-cause mortality and cardiovascular events in patients with CHD or cerebrovascular disease. The different classes of drugs comprising EBCP work in an additive manner, with optimal EBCP conferring the greatest benefit.
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Affiliation(s)
- Tian-Tian Ma
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
| | - Ian C. K. Wong
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Kenneth K. C. Man
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Yang Chen
- UCL Institute of Cardiovascular Science, Univeristy College London, London, United Kingdom
| | - Thomas Crake
- Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Muhiddin A. Ozkor
- Barts Heart Centre, St. Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Ling-Qing Ding
- Department of Pharmacy, The Affiliated Cardiovascular Hospital of Xiamen University, Xiamen, China
| | - Zi-Xuan Wang
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
| | - Lin Zhang
- Intensive Care Unit, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Li Wei
- Research Department of Practice and Policy, UCL School of Pharmacy, London, United Kingdom
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Gong X, Ding X, Chen H, Li H. Real-world use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/β-blocks in Chinese patients before acute myocardial infarction occurs: patient characteristics and hospital follow-up. J Transl Med 2018; 16:346. [PMID: 30526628 PMCID: PMC6288924 DOI: 10.1186/s12967-018-1720-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 12/04/2018] [Indexed: 01/14/2023] Open
Abstract
Background Current guidelines recommend angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin-receptor blockers (ARB) or β-blockers (β-B) for secondary prevention in patients after an acute myocardial infarction (AMI). However, there is limited data to evaluate ACEI/ARB/β-B (AAβ) used before AMI on major adverse cardiovascular events (MACE), in China patients. Objectives This study sought to investigate whether AAβ treatment prior to AMI is associated with better hospital outcomes at the onset of AMI. Methods A total of 2705 patients were selected from the Cardiovascular Center Beijing Friendship Hospital Database Bank, and divided into two groups on the basis of admission prescription: AAβ (n = 872) or no-AAβ (n = 1833). The study was also designed using propensity-score matching (226 AAβ treated patients vs 452 no-AAβ treated patients). The primary outcome was a composite of cardiac death and heart function and infarct size during hospitalization follow-up. Results The mean follow-up period was about 8 days in MACE. The Cox model showed the two groups had similar risk of cardiac death. The in-hospital mortality was 3.36% (3.33% of AAβ users and 3.38% of nonusers, p = 0.94). In adjusted analysis, there was still no difference in in-hospital mortality between the two groups (3.54% vs 2.88%, p = 0.64). However, the AAβ treated patients were associated with better heart function and smaller infarct size than the no-AAβ treated patients. Conclusions The in-hospital MACE was similar between AAβ treated patients and no-AAβ treated patients. However, treatment with AAβ before AMI was associated with improved heart function and smaller infarct size.
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Affiliation(s)
- Xuhe Gong
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Xiaosong Ding
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Hui Chen
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Hongwei Li
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China. .,Department of Internal Medicine, Medical Health Center, Beijing Friendship Hospital, Capital Medical University, Beijing, 100050, People's Republic of China. .,Beijing Key Laboratory of Metabolic Disorder Related Cardiovascular Disease, Beijing, 100069, People's Republic of China.
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. General mechanisms of coagulation and targets of anticoagulants (Section I). Thromb Haemost 2017; 109:569-79. [PMID: 23447024 DOI: 10.1160/th12-10-0772] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 12/25/2012] [Indexed: 01/02/2023]
Abstract
SummaryContrary to previous models based on plasma, coagulation processes are currently believed to be mostly cell surface-based, including three overlapping phases: initiation, when tissue factor-expressing cells and microparticles are exposed to plasma; amplification, whereby small amounts of thrombin induce platelet activation and aggregation, and promote activation of factors (F)V, FVIII and FXI on platelet surfaces; and propagation, in which the Xase (tenase) and prothrombinase complexes are formed, producing a burst of thrombin and the cleavage of fibrinogen to fibrin. Thrombin exerts a number of additional biological actions, including platelet activation, amplification and self-inhibition of coagulation, clot stabilisation and anti-fibrinolysis, in processes occurring in the proximity of vessel injury, tightly regulated by a series of inhibitory mechanisms. ″Classical″ anticoagulants, including heparin and vitamin K antagonists, typically target multiple coagulation steps. A number of new anticoagulants, already developed or under development, target specific steps in the process, inhibiting a single coagulation factor or mimicking natural coagulation inhibitors.
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Eindhoven DC, Hilt AD, Zwaan TC, Schalij MJ, Borleffs CJW. Age and gender differences in medical adherence after myocardial infarction: Women do not receive optimal treatment – The Netherlands claims database. Eur J Prev Cardiol 2017; 25:181-189. [DOI: 10.1177/2047487317744363] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Following myocardial infarction, medication is, besides lifestyle interventions, the cornerstone treatment to improve survival and minimize the occurrence of new cardiovascular events. Still, data on nationwide medication adherence are scarce. This study assesses medical adherence during one year following myocardial infarction, stratifying per type of infarct, age and gender. Design Retrospective cohort study. Methods In The Netherlands, all inhabitants are by law obliged to have health insurance and all claims data are centrally registered. In 2012 and 2013, all national diagnosis-codings of ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) were acquired. Furthermore, information on retrieved medication was extracted from the Dutch Pharmacy Information System. Twelve months after discharge, the retrieved medication at the pharmacy of each pharmacological therapy (aspirin-species, P2Y12-inhibitor, statin, beta-blocker, angiotensin-converting enzyme-/angiotensin 2-inhibitor, vitamin-K antagonists or novel oral anticoagulant) were analysed. Results In total, 59,534 patients (67 ± 13 years, 39,545 (66%) male, 57% NSTEMI) were included, of whom 52,672 (88%) patients were analysed for one-year medical adherence. STEMI patients more often achieved optimal medical adherence than NSTEMI patients (60% vs. 40%, p ≤ 0.001). In both STEMI and NSTEMI, use of all five indicated drugs was higher in male patients compared with female (STEMI male 61% vs. female 57%, p ≤ 0.001; NSTEMI male 43% vs. female 37%, p ≤ 0.001. With increasing age, a gradual decrease was observed in the use of aspirin, P2Y12-inhibitors and statins. Conclusion Age and gender differences existed in medical adherence after myocardial infarction. Medical adherence was lower in women, young patients and elderly patients, specifically in NSTEMI patients.
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Affiliation(s)
| | - Alexander D Hilt
- Department of Cardiology, Leiden University Medical Centre, The Netherlands
| | - Thomas C Zwaan
- Department of Cardiology, Leiden University Medical Centre, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Centre, The Netherlands
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Nguyen T, Le KK, Cao HTK, Tran DTT, Ho LM, Thai TND, Pham HTK, Pham PT, Nguyen TH, Hak E, Pham TT, Taxis K. Association between in-hospital guideline adherence and postdischarge major adverse outcomes of patients with acute coronary syndrome in Vietnam: a prospective cohort study. BMJ Open 2017; 7:e017008. [PMID: 28982823 PMCID: PMC5640016 DOI: 10.1136/bmjopen-2017-017008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE We aimed to determine the association between physician adherence to prescribing guideline-recommended medications during hospitalisation and 6-month major adverse outcomes of patients with acute coronary syndrome in Vietnam. DESIGN Prospective cohort study. SETTING The study was carried out in two public hospitals in Vietnam between January and October 2015. Patients were followed for 6 months after discharge. PARTICIPANTS Patients who survived during hospitalisation with a discharge diagnosis of acute coronary syndrome and who were eligible for receiving at least one of the four guideline-recommended medications. EXPOSURES Guideline adherence was defined as prescribing all guideline-recommended medications at both hospital admission and discharge for eligible patients. Medications were antiplatelet agents, beta-blockers, ACE inhibitors or angiotensin II receptor blockers and statins. MAIN OUTCOME MEASURE Six-month major adverse outcomes were defined as all-cause mortality or hospital readmission due to cardiovascular causes occurring during 6 months after discharge. Cox regression models were used to estimate the association between guideline adherence and 6-month major adverse outcomes. RESULTS Overall, 512 patients were included. Of those, there were 242 patients (47.3%) in the guideline adherence group and 270 patients (52.3%) in the non-adherence group. The rate of 6-month major adverse outcomes was 30.5%. A 29% reduction in major adverse outcomes at 6 months after discharge was found for patients of the guideline adherence group compared with the non-adherence group (adjusted HR, 0.71; 95% CI, 0.51 to 0.98; p=0.039). Covariates significantly associated with the major adverse outcomes were percutaneous coronary intervention, prior heart failure and renal insufficiency. CONCLUSIONS In-hospital guideline adherence was associated with a significant decrease in major adverse outcomes up to 6 months after discharge. It supports the need for improving adherence to guidelines in hospital practice in low-income and middle-income countries like Vietnam.
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Affiliation(s)
- Thang Nguyen
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
| | - Khanh K Le
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hoang T K Cao
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Dao T T Tran
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Linh M Ho
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Trang N D Thai
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Hoa T K Pham
- Cardiac Ward, Can Tho General Hospital, Can Tho, Vietnam
| | - Phong T Pham
- Cardiac Ward, Can Tho Central General Hospital, Can Tho, Vietnam
| | - Thao H Nguyen
- Department of Clinical Pharmacy, School of Pharmacy, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh, Vietnam
| | - Eelko Hak
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
| | - Tam T Pham
- Faculty of Public Health, Can Tho University of Medicine and Pharmacy, Can Tho, Vietnam
| | - Katja Taxis
- Groningen Research Institute of Pharmacy, Unit of PharmacoTherapy, Epidemiology & Economics, University of Groningen, Groningen, The Netherlands
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Mantel Ä, Holmqvist M, Jernberg T, Wållberg-Jonsson S, Askling J. Long-term outcomes and secondary prevention after acute coronary events in patients with rheumatoid arthritis. Ann Rheum Dis 2017; 76:2017-2024. [DOI: 10.1136/annrheumdis-2017-211608] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/14/2017] [Accepted: 07/19/2017] [Indexed: 11/04/2022]
Abstract
ObjectivesPatients with rheumatoid arthritis (RA) are at increased risk of acute coronary syndrome (ACS) and suffer from poorer short-term outcomes after ACS. The aims of this study were to assess long-term outcomes in patients with RA with ACS compared with non-RA patients with ACS, and to investigate whether the use of secondary preventive drugs could explain any differences in ACS outcome.MethodsWe performed a cohort study based on 1135 patients with RA and 3184 non-RA patients who all developed an incident ACS between 2007 and 2010. We assessed 1-year and overall relative risks for ACS recurrence and mortality, as well as prescriptions of standard of care secondary preventive drugs.ResultsThe risk of ACS recurrence, and of mortality, was increased in RA, both at 1 year after adjusting for baseline comorbidities (HR=1.30(95% CI 1.04 to 1.62) and 1.38(95% CI 1.20 to 1.59), respectively) and throughout the complete (mean 2 years) follow-up (HR=1.27(95% CI 1.06 to 1.52) and 1.50(95% CI 1.34 to 1.68), respectively). Among certain subgroups of ACS, there was a tendency of lower usage of statins, whereas there were no apparent differences in others. The increased rates of ACS recurrence and mortality remained in subgroup analyses of individuals whose prescription pattern indicated both adequate initiation and persistence to secondary preventive treatments.ConclusionsPatients with RA suffer from an increased risk of ACS recurrence and of death following ACS compared with general population, which in the present study could not readily be explained by differences in usage of secondary preventive drugs.
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Documento de consenso del uso clínico de la Polypill en la prevención secundaria del riesgo cardiovascular. Med Clin (Barc) 2017; 148:139.e1-139.e15. [DOI: 10.1016/j.medcli.2016.10.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/17/2016] [Accepted: 10/27/2016] [Indexed: 01/13/2023]
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Hemingway H, Feder GS, Fitzpatrick NK, Denaxas S, Shah AD, Timmis AD. Using nationwide ‘big data’ from linked electronic health records to help improve outcomes in cardiovascular diseases: 33 studies using methods from epidemiology, informatics, economics and social science in the ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER) programme. PROGRAMME GRANTS FOR APPLIED RESEARCH 2017. [DOI: 10.3310/pgfar05040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BackgroundElectronic health records (EHRs), when linked across primary and secondary care and curated for research use, have the potential to improve our understanding of care quality and outcomes.ObjectiveTo evaluate new opportunities arising from linked EHRs for improving quality of care and outcomes for patients at risk of or with coronary disease across the patient journey.DesignEpidemiological cohort, health informatics, health economics and ethnographic approaches were used.Setting230 NHS hospitals and 226 general practices in England and Wales.ParticipantsUp to 2 million initially healthy adults, 100,000 people with stable coronary artery disease (SCAD) and up to 300,000 patients with acute coronary syndrome.Main outcome measuresQuality of care, fatal and non-fatal cardiovascular disease (CVD) events.Data platform and methodsWe created a novel research platform [ClinicAl disease research using LInked Bespoke studies and Electronic health Records (CALIBER)] based on linkage of four major sources of EHR data in primary care and national registries. We carried out 33 complementary studies within the CALIBER framework. We developed a web-based clinical decision support system (CDSS) in hospital chest pain clinics. We established a novel consented prognostic clinical cohort of SCAD patients.ResultsCALIBER was successfully established as a valid research platform based on linked EHR data in nearly 2 million adults with > 600 EHR phenotypes implemented on the web portal (seehttps://caliberresearch.org/portal). Despite national guidance, key opportunities for investigation and treatment were missed across the patient journey, resulting in a worse prognosis for patients in the UK compared with patients in health systems in other countries. Our novel, contemporary, high-resolution studies showed heterogeneous associations for CVD risk factors across CVDs. The CDSS did not alter the decision-making behaviour of clinicians in chest pain clinics. Prognostic models using real-world data validly discriminated risk of death and events, and were used in cost-effectiveness decision models.ConclusionsEmerging ‘big data’ opportunities arising from the linkage of records at different stages of a patient’s journey are vital to the generation of actionable insights into the diagnosis, risk stratification and cost-effective treatment of people at risk of, or with, CVD.Future workThe vast majority of NHS data remain inaccessible to research and this hampers efforts to improve efficiency and quality of care and to drive innovation. We propose three priority directions for further research. First, there is an urgent need to ‘unlock’ more detailed data within hospitals for the scale of the UK’s 65 million population. Second, there is a need for scaled approaches to using EHRs to design and carry out trials, and interpret the implementation of trial results. Third, large-scale, disease agnostic genetic and biological collections linked to such EHRs are required in order to deliver precision medicine and to innovate discovery.Study registrationCALIBER studies are registered as follows: study 2 – NCT01569139, study 4 – NCT02176174 and NCT01164371, study 5 – NCT01163513, studies 6 and 7 – NCT01804439, study 8 – NCT02285322, and studies 26–29 – NCT01162187. Optimising the Management of Angina is registered as Current Controlled Trials ISRCTN54381840.FundingThe National Institute for Health Research (NIHR) Programme Grants for Applied Research programme (RP-PG-0407-10314) (all 33 studies) and additional funding from the Wellcome Trust (study 1), Medical Research Council Partnership grant (study 3), Servier (study 16), NIHR Research Methods Fellowship funding (study 19) and NIHR Research for Patient Benefit (study 33).
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Affiliation(s)
- Harry Hemingway
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Gene S Feder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Natalie K Fitzpatrick
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Spiros Denaxas
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Anoop D Shah
- Institute of Health Informatics, University College London, London, UK
- Farr Institute of Health Informatics Research, University College London, London, UK
| | - Adam D Timmis
- Farr Institute of Health Informatics Research, University College London, London, UK
- Barts Health NHS Trust, London, UK
- Farr Institute of Health Informatics Research, Queen Mary University of London, London, UK
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Pinnarelli L, Mayer F, Bauleo L, Agabiti N, Kirchmayer U, Belleudi V, Di Martino M, Autore C, Ricci R, Violini R, Fusco D, Davoli M, Perucci CA. Adherence to antiplatelet therapy after percutaneous coronary intervention: a population study in a region of Italy. J Cardiovasc Med (Hagerstown) 2016; 16:230-7. [PMID: 25325532 DOI: 10.2459/jcm.0000000000000070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS We evaluated adherence to dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) for patients in the Lazio region of Italy and the impact of discharge ward type on therapy discontinuation. METHODS From the Hospital Information System, we selected patients who underwent PCI from 2006 to 2007 and obtained Regional Drug Dispense Registry data for antiplatelet drugs prescribed for 12 months after discharge. Appropriate therapy was defined as DAPT with prescribed daily doses for each drug covering at least 75% of each individual follow-up period. The association between discharge ward type and antiplatelet therapy adherence at 12 months post discharge was estimated using multilevel logistic regression analysis. RESULTS A total of 11 186 patients with PCI were included, and fewer than half (4984; 44.56%) were on adequate DAPT. Only 2930 of 5390 patients (54.36%) with DAPT in the first 6 months post discharge continued DAPT in the second 6 months. Patients discharged from cardiology units or intensive coronary care units were more likely (odds ratio = 1.26; P = 0.003) to receive appropriate antiplatelet therapy, and elderly patients were less likely (odds ratio = 0.65; P < 0.001) to do so. CONCLUSION The proportion of PCI patients receiving appropriate DAPT after discharge is suboptimal in this region, and elderly patients are less likely to receive appropriate therapy. These findings could be important for improving patient management and ensuring adherence to clinical guidelines and indicate the need for a systematic evaluation of the appropriateness of postdischarge therapy.
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Affiliation(s)
- Luigi Pinnarelli
- aDepartment of Epidemiology, Lazio Regional Health Service bDivisione di Cardiologia, Università di Roma La Sapienza, Ospedale Sant'Andrea cDepartment of Cardiology, St Spirito Hospital dDepartment of Interventional Cardiology, Azienda Ospedaliera San Camillo Forlanini eNational Agency for Regional Health Services, Rome, Italy
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Chrischilles EA, Schneider KM, Schroeder MC, Letuchy E, Wallace RB, Robinson JG, Brooks JM. Association Between Preadmission Functional Status and Use and Effectiveness of Secondary Prevention Medications in Elderly Survivors of Acute Myocardial Infarction. J Am Geriatr Soc 2016; 64:526-35. [PMID: 26928940 DOI: 10.1111/jgs.13953] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To determine whether function-related indicators (FRIs), derived from preadmission claims data, help explain the frequent practice of forgoing secondary prevention medications observed in Medicare. DESIGN Retrospective cohort. SETTING National Medicare data. PARTICIPANTS Elderly Medicare beneficiaries discharged alive from an acute myocardial infarction (AMI) hospitalization in 2007-2008 (N = 184,156). MEASUREMENTS Study outcomes were number of guideline-recommended secondary prevention medications (statins, beta-blockers, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) used after discharge and 12-month survival. Preadmission data (FRIs, cardiovascular conditions, comorbid conditions), type of AMI (non-ST-elevation myocardial infarction, anterior, other), and procedures and complications during the hospitalization were from claims data. RESULTS Function-related indicators (FRIs) were common before admission; 50% of individuals had at least one (range 0-11). After discharge, 85.8% used at least one class of guideline medication, and 30.2% used all three; 19.6% died within 12 months. Each additional FRI reduced the likelihood of receiving all three medication classes by 5% (adjusted odds ratio = 0.95, 95% confidence interval (CI) = 0.94-0.96) and increased 12-month mortality by 20% (adjusted hazard ratio (aHR) = 1.20, 95% CI = 1.19-1.21). Individuals taking all three classes of medication were 30% less likely to die within 12 months than those not taking guideline medications (aHR = 0.70, 95% CI = 0.67-0.73). Similar survival benefit was observed in individuals with and without functional impairments. CONCLUSION Greater impairment in preadmission functional status, using a measure derived from claims data, was associated with less use of secondary prevention medications after AMI. Survival benefits of taking these medications were consistent across functional impairment levels.
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Affiliation(s)
| | - Kathleen M Schneider
- Schneider Research Associates, LLC, Des Moines, Iowa.,Buccaneer, A General Dynamics Company, West Des Moines, Iowa
| | - Mary C Schroeder
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Iowa, Iowa City, Iowa
| | - Elena Letuchy
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Robert B Wallace
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - Jennifer G Robinson
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
| | - John M Brooks
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
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Lee PH, Park GM, Kim YH, Yun SC, Chang M, Roh JH, Yoon SH, Ahn JM, Park DW, Kang SJ, Lee SW, Lee CW, Park SW, Park SJ. Effect of Beta Blockers and Renin-Angiotensin System Inhibitors on Survival in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention. Medicine (Baltimore) 2016; 95:e2971. [PMID: 26962802 PMCID: PMC4998883 DOI: 10.1097/md.0000000000002971] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Because it remains uncertain whether β-blockers (BBs) and/or renin-angiotensin system inhibitors benefit a broad population of acute myocardial infarction (AMI) patients, we sought to evaluate the effectiveness of these drugs in improving survival for post-AMI patients who underwent a percutaneous coronary intervention (PCI).From the nationwide data of the South Korea National Health Insurance, 33,390 patients with a diagnosis of AMI who underwent a PCI between 2009 and 2013 and survived at least 30 days were included in this study. We evaluated the risk of all-cause death for patients treated with both BB and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor antagonist (ARB) (n = 16,280), only BB (n = 3683), and only ACEI/ARB (n = 9849), with the drug-untreated patients (n = 3578) as the reference.Over a median follow-up of 2.4 years, although treated patients displayed a trend toward improved survival, there were no significant differences in the adjusted risk of all-cause death when patients were treated with both drugs (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.70-1.06, P = 0.154), BB (HR 0.88, 95% CI 0.68-1.14, P = 0.325), or ACEI/ARB (HR 0.84, 95% CI 0.68-1.04, P = 0.111). No additional benefit was found for the combination therapy compared with either isolated BB (HR 0.98, 95% CI 0.80-1.21, P = 0.856) or ACEI/ARB (HR 1.03, 95% CI 0.89-1.19, P = 0.727) therapy.Treatment with BB and/or ACEI/ARB has limited effect on survival in unselected nonfatal AMI patients who undergo PCI.
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Affiliation(s)
- Pil Hyung Lee
- From the Department of Cardiology (PHL, Y-HK, MC, J-HR, S-HY, J-MA, D-WP, S-JK, S-WL, CWL, S-WP, S-JP); Division of Biostatistics (S-CY), Center for Medical Research and Information, Asan Medical Center, University of Ulsan College of Medicine; and Department of Cardiology (G-MP), Daejeon St Mary's Hospital, The Catholic University of Korea, Daejeon, Seoul, Korea
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Akoudad H, El Khorb N, Sekkali N, Mechrafi A, Zakari N, Ouaha L, Lahlou I. [Acute myocardial infarction in Morocco: FES-AMI registry data]. Ann Cardiol Angeiol (Paris) 2015; 64:434-438. [PMID: 26492984 DOI: 10.1016/j.ancard.2015.09.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Acute myocardial infarction is the most dangerous complication of coronary atherothrombosis. There are several disparities in regard to its management around the world. The aim of this study is to analyze the specificities of management of acute myocardial infarction in Morocco. METHODS FES-AMI (Fès Acute Myocardial Infarction) is a prospective monocentric registry conducted in cardiology department of Hassan II university hospital in Fès. In this registry, we enrolled patients with acute myocardial infarction who presented within 5 days after symptom onset. RESULTS From January 2005 to August 2015, we enrolled 1835 patients. Seventy-five percent of patients were males and mean age was 60 years old. Fifty-one percent of patients were smokers, 27% were hypertensives and 14% were diabetics. Sixty-six percent of patients had more than 2 risk factors. Time from symptom onset to hospital admission was less than six hours for 40% of the patients. Thirty-six percent of patients were admitted more than twelve hours after the onset of chest pain. Only 37% of patients received reperfusion therapy, 31% with in-hospital thrombolysis and 6% with primary angioplasty. In-hospital mortality was 7.6%. CONCLUSION The patients enrolled in our registry have late presentation of acute myocardial infarction and less rate of reperfusion therapy. Furthermore, the majority of our patients have multiple risk factors and this result underlines the failure of preventive interventions.
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Affiliation(s)
- H Akoudad
- Service de cardiologie, CHU Hassan II, Fès, Maroc.
| | - N El Khorb
- Service de cardiologie, CHU Hassan II, Fès, Maroc
| | - N Sekkali
- Service de cardiologie, CHU Hassan II, Fès, Maroc
| | - A Mechrafi
- Service de cardiologie, CHU Hassan II, Fès, Maroc
| | - N Zakari
- Service de cardiologie, CHU Hassan II, Fès, Maroc
| | - L Ouaha
- Service de cardiologie, CHU Hassan II, Fès, Maroc
| | - I Lahlou
- Service de cardiologie, CHU Hassan II, Fès, Maroc
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Jiang XL, Samant S, Lesko LJ, Schmidt S. Clinical pharmacokinetics and pharmacodynamics of clopidogrel. Clin Pharmacokinet 2015; 54:147-66. [PMID: 25559342 DOI: 10.1007/s40262-014-0230-6] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute coronary syndromes (ACS) remain life-threatening disorders, which are associated with high morbidity and mortality. Dual antiplatelet therapy with aspirin and clopidogrel has been shown to reduce cardiovascular events in patients with ACS. However, there is substantial inter-individual variability in the response to clopidogrel treatment, in addition to prolonged recovery of platelet reactivity as a result of irreversible binding to P2Y12 receptors. This high inter-individual variability in treatment response has primarily been associated with genetic polymorphisms in the genes encoding for cytochrome (CYP) 2C19, which affect the pharmacokinetics of clopidogrel. While the US Food and Drug Administration has issued a boxed warning for CYP2C19 poor metabolizers because of potentially reduced efficacy in these patients, results from multivariate analyses suggest that additional factors, including age, sex, obesity, concurrent diseases and drug-drug interactions, may all contribute to the overall between-subject variability in treatment response. However, the extent to which each of these factors contributes to the overall variability, and how they are interrelated, is currently unclear. The objective of this review article is to provide a comprehensive update on the different factors that influence the pharmacokinetics and pharmacodynamics of clopidogrel and how they mechanistically contribute to inter-individual differences in the response to clopidogrel treatment.
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Affiliation(s)
- Xi-Ling Jiang
- Department of Pharmaceutics, Center for Pharmacometrics and Systems Pharmacology, University of Florida at Lake Nona (Orlando), 6550 Sanger Road, Room 467, Orlando, FL, 32827, USA
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Tra J, van der Wulp I, Appelman Y, de Bruijne MC, Wagner C. Adherence to guidelines for the prescription of secondary prevention medication at hospital discharge after acute coronary syndrome: a multicentre study. Neth Heart J 2015; 23:214-21. [PMID: 25884093 PMCID: PMC4368527 DOI: 10.1007/s12471-015-0664-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background The prescription of guideline-recommended medication for secondary prevention after acute coronary syndrome has been suboptimal in the past. In the present study, guideline adherence and associated patient, care and hospital characteristics at hospital discharge after acute coronary syndrome were studied. Methods Charts of patients with acute coronary syndrome discharged from 13 Dutch hospitals in 2012 were reviewed. Guideline adherence was defined as the prescription of acetylsalicylic acid, P2Y12 receptor inhibitor, statin, beta-blocker and angiotensin-converting enzyme (ACE) inhibitor at discharge, or a documented contraindication. Associated characteristics were identified by means of generalized linear mixed models for binary outcomes. Results In total, 2471 patients were included. Complete guideline adherence was achieved in 69.1 % of the patients, ranging from 42.1 to 87.0 % between hospitals. The ACE inhibitor was most often missing (21.2 %). Patients with non-ST-segment elevation myocardial infarction or unstable angina, patients with a history of coronary artery bypass grafting or elderly women were less likely to be discharged with the guideline-recommended medication. Conclusions Guideline adherence for secondary prevention medication following acute coronary syndrome was substantial; however, variation between hospitals and patient groups was found. Efforts to increase guideline adherence can focus on underperforming hospitals and undertreated patient groups.
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Affiliation(s)
- J Tra
- Department of Public and Occupational health, EMGO+/VU University medical center, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands,
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Al-Khadra S, Meisinger C, Amann U, Holle R, Kuch B, Seidl H, Kirchberger I. Secondary prevention medication after myocardial infarction: persistence in elderly people over the course of 1 year. Drugs Aging 2015; 31:513-25. [PMID: 24919974 DOI: 10.1007/s40266-014-0189-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS Persistent use of guideline-recommended drugs after acute myocardial infarction (AMI) is frequently reported to be inadequate in the elderly and scarce knowledge exists about factors that influence persistence in outpatient care. Our aim was to evaluate drug use and its predictors in survivors of AMI above 64 years from hospital discharge to 1-year post-AMI. METHODS In a single-centre randomised controlled trial, discharge medication of 259 patients with AMI was obtained from medical records at hospital stay. Follow-up drug use and use of the healthcare system were self-reported to study nurses over 1 year in 3-month intervals. Predictors for persistence were modelled with multivariate logistic regression analysis considering demographics, co-morbidities and treatment characteristics. RESULTS At discharge, 99.2 % of the patients used anti-platelets, 86.5 % beta blockers, 95.0 % statins and 90.4 % angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Use of the combination of all four drug classes decreased from discharge to 1 year post-AMI from 74.1 to 37.8 % and was significantly reduced by age ≥75 years (odds ratio [OR] 0.49; 95 % confidence interval [CI] 0.29-0.85) and ten or more visits with general practitioners (GPs) over 1 year (OR 0.29; 95 % CI 0.17-0.51). Persistence from month 3 to 12 was significantly associated with drug use at discharge for the single drug classes, but not for the drug combination. CONCLUSION Older age and frequent GP visits are associated with decreased use of the guideline-recommended drug combination after AMI. Further research is needed to specify underlying reasons and develop measures to improve persistence.
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Affiliation(s)
- Saba Al-Khadra
- Central Hospital of Augsburg, MONICA/KORA Myocardial Infarction Registry, Augsburg, Germany
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Wallentin L, Kristensen SD, Anderson JL, Tubaro M, Sendon JLL, Granger CB, Bode C, Huber K, Bates ER, Valgimigli M, Steg PG, Ohman EM. How can we optimize the processes of care for acute coronary syndromes to improve outcomes? Am Heart J 2014; 168:622-31. [PMID: 25440789 DOI: 10.1016/j.ahj.2014.07.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Accepted: 07/17/2014] [Indexed: 01/14/2023]
Abstract
Acute coronary syndromes (ACS), either ST-elevation myocardial infarction or non-ST-elevation ACS, are still one of the most common cardiac emergencies with substantial morbidity and mortality. The availability of evidence-based treatments, such as early and intense platelet inhibition and anticoagulation, and timely reperfusion and revascularization, has substantially improved outcomes in patients with ACS. The implementation of streamlined processes of care for patients with ST-elevation myocardial infarction and non-ST-elevation ACS over the last decade including both appropriate tools, especially cardiac troponin, for rapid diagnosis and risk stratification and for decision support, and the widespread availability of modern antithrombotic and interventional treatments, have reduced morbidity and mortality to unprecedented low levels. These changes in the process of care require a synchronized approach, and research using a team-based strategy and effective regional networks has allowed healthcare systems to provide modern treatments for most patients with ACS. There are still areas needing improvement, such as the delivery of care to people in rural areas or with delayed time to treatment.
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[Antiplatelet therapy in acute coronary syndrome. Prehospital phase: nothing, aspirin or what?]. Herz 2014; 39:803-7. [PMID: 25315248 DOI: 10.1007/s00059-014-4157-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
In most cases of ST segment elevation myocardial infarction (STEMI) a major coronary vessel is occluded by a thrombus. This is why early and effective antiplatelet therapy plays a key role. The current guidelines recommend the administration of dual antiplatelet therapy as early as possible. Despite the lack of convincing clinical evidence, prehospital administration appears reasonable, primarily because of pharmacokinetic considerations. Ticagrelor should be preferentially administered because the largest amount of evidence is available and it appears to be safe. In high-risk patients undergoing transfer to a catheterization laboratory, upstream use of a glycoprotein (GP) IIb/IIIa receptor antagonist (tirofiban) may be considered. Acute coronary syndrome without ST segment elevation (NSTE-ACS) represents a clinically heterogeneous group. Current guidelines recommend that antiplatelet therapy should be initiated as early as possible when the diagnosis of NSTE-ACS is made. If there is high clinical suspicion of NSTE-ACS acetylsalicylic acid (ASA) should be given before hospital admission. In high-risk patients prehospital administration of ticagrelor may be considered.
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Kirchmayer U, Di Martino M, Agabiti N, Bauleo L, Fusco D, Belleudi V, Arcà M, Pinnarelli L, Perucci CA, Davoli M. Effect of evidence-based drug therapy on long-term outcomes in patients discharged after myocardial infarction: a nested case–control study in Italy. Pharmacoepidemiol Drug Saf 2014; 22:649-57. [PMID: 23529919 PMCID: PMC3746119 DOI: 10.1002/pds.3430] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Revised: 01/17/2013] [Accepted: 02/04/2013] [Indexed: 11/30/2022]
Abstract
Purpose There are some methodological concerns regarding results from observational studies about the effectiveness of evidence-based (EB) drug therapy in secondary prevention after myocardial infarction. The present study used a nested case–control approach to address these major methodological limitations. Methods A cohort of 6880 patients discharged from hospital after acute myocardial infarction (AMI) in 2006–2007 was enrolled and followed-up throughout 2009. Exposure was defined as adherence to each drug in terms of the proportion of days covered (cutoff ≥ 75%). Composite treatment groups, that is, groups with no EB therapy or therapy with one, two, three, or four EB drugs), were analyzed. Outcomes were overall mortality and reinfarction. Nested case–control studies were performed for both outcomes, matching four controls to every case (841 deaths, 778 reinfarctions) by gender, age, and individual follow-up. The association between exposure to EB drug therapy and outcomes was analyzed using conditional logistic regression, adjusting for revascularization procedures, comorbidities, duration of index admission, and use of the study drugs prior to admission. Results Mortality and reinfarction risk decreased with the use of an increasing number of EB drugs. Combinations of two or more EB drugs were associated with a significant protective effect (p < 0.001) versus no EB drugs (mortality: 4 EB drugs: ORadj = 0.35; 95%CI: 0.21–0.59; reinfarction: 4 EB drugs: ORadj = 0.23; 95%CI: 0.15–0.37). Conclusions These findings of the beneficial effects of EB polytherapy on mortality and morbidity in a population-based setting using a nested case–control approach strengthen existing evidence from observational studies. Copyright © 2013 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
- *Correspondence to: U. Kirchmayer, Department of Epidemiology, Lazio Regional Health Service, Via di Santa Costanza, 53-00198 Roma, Italy. E-mail:
| | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Lisa Bauleo
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Massimo Arcà
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | - Luigi Pinnarelli
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
| | | | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health ServiceRome, Italy
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Amann U, Kirchberger I, Heier M, Golüke H, von Scheidt W, Kuch B, Peters A, Meisinger C. Long-term survival in patients with different combinations of evidence-based medications after incident acute myocardial infarction: results from the MONICA/KORA Myocardial Infarction Registry. Clin Res Cardiol 2014; 103:655-64. [DOI: 10.1007/s00392-014-0688-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/12/2014] [Indexed: 11/29/2022]
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Naci H, Brugts JJ, Fleurence R, Ades AE. Dose-comparative effects of different statins on serum lipid levels: a network meta-analysis of 256,827 individuals in 181 randomized controlled trials. Eur J Prev Cardiol 2013; 20:658-70. [DOI: 10.1177/2047487313483600] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Huseyin Naci
- London School of Economics & Political Science, London, UK
| | | | | | - AE Ades
- University of Bristol, Bristol, UK
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Roggeri DP, Roggeri A, Rossi E, Cinconze E, De Rosa M, Maggioni AP. Direct healthcare costs and resource consumption after acute coronary syndrome: a real-life analysis of an Italian subpopulation. Eur J Prev Cardiol 2013; 21:1090-6. [PMID: 23515447 DOI: 10.1177/2047487313483608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Acute coronary syndrome (ACS) is the most common cause of morbidity and mortality in Italy and worldwide. Aim of this study was to evaluate the average annual direct healthcare costs for the treatment of patients with a recent hospitalization for ACS. DESIGN AND METHODS The direct medical costs of patients with a first ACS hospitalization (index event) in the period from 1 January 2008 to 31 December 2008 were estimated for a 1-year follow-up period. The resource consumption was measured in terms of: reimbursed drugs, diagnostic procedures, outpatient visits, and hospitalizations. The analysis was performed from the Italian National Health Service perspective. RESULTS A total of 2,758,872 subjects were observed, 7082 (35.8% women) of whom being hospitalized for ACS during the accrual period (2.6 ‰). Among patients with ACS, 60% were medically treated, 33.1% were treated with percutaneous coronary intervention (PCI), and 6.9% died during the index hospitalization. Dual antiplatelet treatment (ASA plus clopidogrel) was prescribed in 25.9% of the medically treated ACS patients and in 70.1% of the ACS patients treated with PCI. The average yearly cost per patient for the total ACS population was 11,464€/year (drugs 1,304€; hospitalizations 9,655€; diagnostic and outpatient visits 505€). The average annual cost was 10,862€ for medically treated patients and 14,111€ for patients treated with PCI. Patients who died of cardiovascular events during follow up had an average cost of 16,231€/patient. CONCLUSIONS Patients with ACS had higher direct healthcare costs, their management and rehospitalizations being the main cost drivers.
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Affiliation(s)
| | | | - Elisa Rossi
- CINECA, Interuniversity Consortium, Bologna, Italy
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Bruthans J, Cífková R, Lánská V, O'Flaherty M, Critchley JA, Holub J, Janský P, Zvárová J, Capewell S. Explaining the decline in coronary heart disease mortality in the Czech Republic between 1985 and 2007. Eur J Prev Cardiol 2012. [PMID: 23180867 DOI: 10.1177/2047487312469476] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Coronary heart disease (CHD) mortality has declined substantially in the Czech Republic over the last two decades. DESIGN The purpose of this study was to determine what proportion of this CHD mortality decline could be associated with temporal trends in major CHD risk factors and what proportion with advances in medical and surgical treatments. METHODS The validated IMPACT mortality model was used to combine and analyse data on uptake and effectiveness of CHD management and risk factor trends in the Czech Republic in adults aged 25-74 years between 1985 and 2007. The main sources were official statistics, national quality of care registries, published trials and meta-analyses, and the Czech MONICA and Czech post-MONICA studies. RESULTS Between 1985 and 2007, age-adjusted CHD mortality rates in the Czech Republic decreased by 66.2% in men and 65.4% in women in the age group 25-74 years, representing 12,080 fewer CHD deaths in 2007. Changes in CHD risk factors explained approximately 52% of the total mortality decrease, and improvements in medical treatments approximately 43%. Increases in body mass index and in diabetes prevalence had a negative impact, increasing CHD mortality by approximately 1% and 5%, respectively. CONCLUSIONS More than half of the very substantial fall in CHD mortality in the Czech Republic between 1985 and 2007 was attributable to reduction in major cardiovascular risk factors. Improvement in treatments accounted for approximately 43% of the total mortality decrease. These findings emphasize the value of primary prevention and evidence-based medical treatment.
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Affiliation(s)
- Jan Bruthans
- Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Department of Medicine II, Charles University Medical School, Pilsen, Czech Republic
| | - Renata Cífková
- Department of Preventive Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Centre for Cardiovascular Prevention, Thomayer Hospital and Charles University Medical School I, Prague, Czech Republic Department of Medicine II, Charles University Medical School I, Prague, Czech Republic International Clinical Research Centre Brno, Czech Republic
| | - Věra Lánská
- Medical Statistics Unit, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | | | - Jiří Holub
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Petr Janský
- Department of Cardiovascular Surgery, Charles University Medical School II and Motol University Hospital, Prague, Czech Republic
| | - Jana Zvárová
- Centre of Biomedical Informatics, Institute of Computer Science, Academy of Sciences of the Czech Republic, Prague, Czech Republic
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Riley RF, Don CW, Aldea GS, Mokadam NA, Probstfield J, Maynard C, Goss JR. Recent Trends in Adherence to Secondary Prevention Guidelines for Patients Undergoing Coronary Revascularization in Washington State: An Analysis of the Clinical Outcomes Assessment Program (COAP) Registry. J Am Heart Assoc 2012; 1:e002733. [PMID: 26600570 PMCID: PMC4942980 DOI: 10.1161/jaha.112.002733] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Accepted: 06/15/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies indicated that patients undergoing coronary artery bypass graft (CABG) surgery are less likely to receive guideline-based secondary prevention therapy than are those undergoing percutaneous coronary intervention (PCI) after an acute myocardial infarction. We aimed to evaluate whether these differences have persisted after the implementation of public reporting of hospital metrics. METHODS AND RESULTS The Clinical Outcomes Assessment Program (COAP) database was analyzed retrospectively to evaluate adherence to secondary prevention guidelines at discharge in patients who underwent coronary revascularization after an acute ST-elevation myocardial infarction in Washington State. From 2004 to 2007, 9260 patients received PCI and 692 underwent CABG for this indication. Measures evaluated included prescription of aspirin, β-blockers, angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, or lipid-lowering medications; cardiac rehabilitation referral; and smoking-cessation counseling. Composite adherence was lower for CABG than for PCI patients during the period studied (79.6% versus 89.7%, P<0.01). Compared to patients who underwent CABG, patients who underwent PCI were more likely to receive each of the pharmacological therapies. There was no statistical difference in smoking-cessation counseling (91.7% versus 90.3%, P=0.63), and CABG patients were more likely to receive referral for cardiac rehabilitation (70.9% versus 48.3%, P<0.01). Adherence rates improved over time among both groups, with no significant difference in composite adherence in 2006 (85.6% versus 87.6%, P=0.36). CONCLUSIONS Rates of guideline-based secondary prevention adherence in patients with ST-elevation myocardial infarction who underwent CABG surgery have been improving steadily in Washington State. The improvement possibly is associated with the implementation of public reporting of quality measures.
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Affiliation(s)
- Robert F. Riley
- Section on Cardiology Wake Forest University Health SciencesWinston‐SalemNC
| | | | | | | | | | | | - J. Richard Goss
- Division of General Internal Medicine Harborview Medical CenterSeattleWA
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[Outpatient rehabilitation after myocardial infarction or for heart failure]. Herz 2012; 37:30-7. [PMID: 22231550 DOI: 10.1007/s00059-011-3557-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Reducing cardiac mortality and improving quality of life are the main objectives of cardiac rehabilitation. In recent years, outpatient rehabilitation within easy patient reach has achieved the same status as inpatient rehabilitation. Outpatient rehabilitation permits close involvement of the patient's family and social environment, thus easing reintegration into everyday life. However, the health care system is not yet utilizing outpatient rehabilitation to its full potential. This contribution illustrates the principles of rehabilitation following myocardial infarction or for heart failure in an outpatient setting, as well as its potential and future development.
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Domburg RTV, Hendriks JM, Kamp O, Smits P, Melle MV, Schenkeveld L, Bax JJ, Simoons ML. Three life years gained after reperfusion therapy in acute myocardial infarction: 25−30 years after a randomized controlled trial. Eur J Prev Cardiol 2011; 19:1316-23. [DOI: 10.1177/1741826711428064] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Otto Kamp
- VU University Medical Center, Amsterdam, The Netherlands
| | - Peter Smits
- Maasstad Hospital, Rotterdam, The Netherlands
| | | | | | - Jeroen J Bax
- Leids University Medical Center, Leiden, The Netherlands
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Xie HG, Zou JJ, Hu ZY, Zhang JJ, Ye F, Chen SL. Individual variability in the disposition of and response to clopidogrel: Pharmacogenomics and beyond. Pharmacol Ther 2011; 129:267-89. [DOI: 10.1016/j.pharmthera.2010.10.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2010] [Accepted: 10/06/2010] [Indexed: 01/08/2023]
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Bibliography-Editors' selection of current word literature. Coron Artery Dis 2010; 22:45-7. [PMID: 21160292 DOI: 10.1097/mca.0b013e328342fc9d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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[Registries of myocardial infarction in Germany. Consequences for drug therapy of patients with acute ST elevation myocardial infarction]. Internist (Berl) 2010; 51:1324-7, 1329. [PMID: 20725707 DOI: 10.1007/s00108-010-2662-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Current national and international guidelines for patients with ST elevation myocardial infarction (STEMI) are mainly based on the results of randomised clinical trials. However, it is well perceived that patients in such trials often represent a low risk population. Therefore the results of randomised clinical trials are not necessarily applicable to patients in clinical practice. This gap can be filled by prospective registries. Since the early nineties a number of prospective large registries in patients with STEMI have been performed in Germany. It could be shown that guideline adherent acute therapies and secondary prevention therapies were associated with an improvement in inhospital and mid-term outcomes. The benefit of guideline adherent therapy observed was especially high in patients with higher baseline risk. Registries are not able to replace randomised clinical trials, but can help to test if the results of these trials are comprehensible in clinical practice. Therefore prospective STEMI registries are an important part of clinical research to optimize therapies and improve outcome in patients with STEMI.
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Porzsolt F. Lessons learned from prevention programs: different endpoints should be used in secondary and tertiary prevention. Recent Results Cancer Res 2010; 188:11-20. [PMID: 21253786 DOI: 10.1007/978-3-642-10858-7_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
It is mandatory to compare cost and consequences of healthcare services if public support is requested. This request will apply to all healthcare services including prevention. As the demand for health care will always exceed the available resources, methods that make it possible to select the "best" programs for implementation have to be developed. The selection of the "best" programs is not easy because there exist so far no generally accepted quality criteria that can be used to identify the "best" prevention programs.Based on a model on structural and functional properties of a disease, it is concluded that the traditional outcomes of treatment and prevention may be useful for the evaluation of tertiary prevention programs, but not of secondary prevention programs. Neither the traditional endpoints of treatment studies nor traditional surrogate parameters are useful for the evaluation of secondary prevention programs.Using the assumptions of the model and a list of available data in secondary prevention programs we recommend to assess five indicators for description of the value of a secondary prevention program: quality of life, surrogates for life expectancy, the perspective of the assessor, the conditions of assessment, and finally the payment. As each of these five items offers two possible values prevention programs may be classified into 32 different groups.
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