Suboptimal medical therapy for ACS patients is associated with increased mortality
Trends in Optimal Medical Therapy Prescription and Mortality After Admission for Acute Coronary Syndrome: a 9-Year Experience in a Real-World SettingHoedemaker NPG, Damman P, Ottervanger JP, et al. - Eur Heart J - CV Pharmacotherapy 2018
European Society of Cardiology (ESC) guidelines for the treatment of ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) recommend the use of aspirin, P2Y12 inhibitors, and statins in all patients with these conditions, as well as beta-blockers, and angiotensin-converting enzyme inhibitors (ACEi) or angiotensin-receptor blockers (ARB) in those with additional left ventricular systolic dysfunction (LVSD) or heart failure (HF) [1,2].
In this study, the association between prescription of medical therapy in acute coronary syndrome patients and mortality was assessed in a Dutch tertiary hospital. All consecutive STEMI and NSTEMI patients from 2006 until 2014 were included in the analysis. The main prescription measures were optimal medical therapy (OMT) prescription, defined as the combination of aspirin, P2Y12 inhibitor, statin, beta-blocker, and ACEi/ARB, and prescription (APS) of at least aspirin, P2Y12 inhibitors and a statin at discharge, 30 days, and 1 year. The endpoints were all-cause death and cardiac mortality.
- During 9 years, a total of 9,202 consecutive patients were included, with a mean age of 65.7 years. 29.9% of patients were women, and 61.1% of patients had a STEMI.
- Prescription was known in 91.1% of patients alive at discharge, 77.5% at 30 days, and 58.7% at 1 year.
- Prescription of APS at discharge, 30-days, and 1-year was 70.6%, 70.8% and 44.6% respectively, and 46.6%, 51.4%, and 29.4% for OMT. Use of OMT did not change significantly for the duration of the study, despite the change of ESC guidelines during this period.
- There were no significant changes in all-cause and cardiac in-hospital, 30-day, and 1-year mortality during the study period.
- OMT prescription at discharge was associated with a reduction in 1-year mortality before and after adjustment (HR: 0.35; 95%CI: 0.28-0.44; HRadj: 0.66; 95%CI: 0.46-0.93).
- In patients with a known IA indication for both beta-blockers and ACEi/ARBs (i.e. LVEF ≤40%, in 48.5% of patients with this data available) at discharge, co-prescription of at least beta-blockers and ACEi/ARBS was 66.0%, and OMT prescription at discharge was 41.6%.
In a single-center observational study, less than 50% of acute coronary syndrome patients were on aspirin, P2Y12 inhibitor, statin, beta-blocker, and ACEi/ARB at discharge. The prescription of these recommended therapies at discharge was associated with a reduction in 1-year mortality.