Optimal medical therapy at discharge in patients with acute coronary syndromes: Temporal changes, characteristics, and 1-year outcome

doi:10.1016/j.ahj.2007.07.040

American Heart Journal

Volume 154, Issue 6, December 2007, Pages 1108-1115

https://doi.org/10.1016/j.ahj.2007.07.040 Get rights and content

Background

There are limited data on the recent trend in the use of optimal evidence-based medical therapies after acute coronary syndromes (ACSs). We sought to evaluate (1) the temporal changes in medical management of patients discharged after an ACS; (2) patient and practice characteristics associated with optimal medical therapy at discharge; and (3) the association between discharge medication use and 1-year outcome.

Methods

The Canadian ACS I (September 1999-June 2001) and ACS II (October 2002-December 2003) Registries were prospective, multicenter, observational studies of 6853 patients admitted for ACS. We examined the discharge use of medications among 5833 hospital survivors who did not have any contraindications to antiplatelet/anticoagulant, β-blocker, angiotensin-converting enzyme inhibitor, or lipid-modifying therapies. Optimal medical therapy was defined as the use of all indicated medications. Follow-up data at 1 year were collected by telephone interview. We performed hierarchical logistic regression to identify patient characteristics and care patterns associated with optimal medical treatment and to examine its relationship with 1-year mortality.

Results

There were significant increases in the discharge use of all 4 classes of medications over time; 28.9% and 51.8% of patients in ACS I and ACS II Registries, respectively, were prescribed optimal medical therapy (P < .001). Advanced age, female sex, prior heart failure, renal dysfunction, and coronary bypass surgery during hospitalization were negative independent predictors of optimal medical therapy. Conversely, enrollment in ACS II Registry, history of dyslipidemia, presence of ST elevation and abnormal cardiac biomarker, previous myocardial infarction, and previous coronary revascularization were independently associated with the use of combination therapy. After adjusting for other validated prognosticators, patients receiving optimal medical therapy had significantly lower 1-year mortality (adjusted odds ratio 0.54, 95% confidence interval 0.36-0.81, P = .003) compared with those given 0 or 1 drug at discharge. Over the 1-year follow-up period, substantial numbers of patients discontinued therapies, whereas others were initiated on treatment.

Conclusions

Despite the temporal increases in the combined use of evidence-based pharmacologic therapies, which is associated with improved outcome, medical management of ACS remains suboptimal. Quality improvement strategies are needed to enhance the appropriate use of effective therapies, targeting specifically the high-risk but undertreated patients who may derive the greatest therapeutic benefit.

Section snippets

Study design and patient population

Details of the Canadian ACS Registry have been published.¹⁷ In brief, the Canadian ACS I and ACS II Registries were prospective, multicenter, observational studies of management practices and outcomes of ACS in Canada. Eligible patients were (1) ≥18 years old on presentation; (2) admitted to hospital with a presumptive diagnosis of ACS (symptoms of acute cardiac ischemia within 24 hours of onset); and (3) with qualifying ACS not precipitated by a serious concurrent illness such as trauma. To

Results

Of the 5833 patients with ACS in the present study, 372 (6.4%), 3370 (57.8%), and 2091 (35.6%) patients were discharged on 0 or 1 drug, 2 or 3 drugs, and optimal medical therapy, respectively. Tables I and II summarize the baseline characteristics and inhospital management patterns, respectively, of the overall study patients.

Figure 1 depicts the discharge prescription rates in ACS I and ACS II Registries. The results of multivariable analysis for optimal medication use at discharge are

Discussion

In this Canadian prospective observational study of a wide spectrum of ACS, we found substantial temporal increases in the use of evidence-based therapies at discharge and at 1-year follow-up. Importantly, the use of optimal medical therapy at discharge was independently associated with improved survival. Nevertheless, this combination therapy was only prescribed in a minority of eligible patients. Furthermore, its use was paradoxically less common among high-risk patients.

Although randomized

Conclusion

In conclusion, despite the temporal increases in the combined use of evidence-based pharmacologic therapies, which is associated with improved outcome, medical management of ACS remains suboptimal outside of randomized controlled trials in the real world. Our findings underscore an important opportunity for quality improvement strategies to promote more widespread use of proven therapies across the broad spectrum of ACS, targeting in particular the high-risk patients who may derive the most

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Emulated Trial for Discharge Prescription of Guideline-Directed Medical Therapy and 15-Year Survival After Coronary Artery Bypass Graft Surgery
2024, Mayo Clinic Proceedings
To explore admission and discharge prescription rates of guideline-directed medical therapy (GDMT), defined as aggregate antiplatelet agents, statins, and β-blockers, after coronary artery bypass graft (CABG) surgery and to reveal its association with long-term survival.
This is a prospective cohort study–based emulated trial of patients undergoing elective or semi-elective isolated CABG surgery in 7 cardiothoracic units in Israel from January 1, 2004, to December 31, 2007, and followed up until December 31, 2020, for all-cause mortality.
Only 59.2% of 968 patients (n=573) were discharged on GDMT after CABG surgery. Admission GDMT use conferred a 7 times greater likelihood of discharge GDMT prescription (odds ratio, 7.07; 95% CI, 5.04 to 9.91; P<.001), with no sex differences observed. After applying inverse probability of treatment weighting, baseline characteristics were well balanced between groups. During a median follow-up of 13.7 years, a Cox regression model with propensity score–adjusted inverse probability of treatment weighting revealed lower mortality in patients with discharge GDMT prescription who underwent CABG surgery than in their counterparts (hazard ratio, 0.75; 95% CI, 0.60 to 0.93; P=.008).
The use of aggregate GDMT before surgery conferred a greater likelihood of GDMT prescription upon discharge, which, in turn, is associated with better long-term survival. Educational efforts of pertinent medical professionals are needed to minimize preventive treatment gaps.
clinicaltrials.gov Identifier: NCT00356863
Drug Adherence and Long-Term Outcomes in Non-Revascularized Patients Following Acute Myocardial Infarction
2021, American Journal of Cardiology
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.
Trends in optimal medical therapy at discharge and clinical outcomes in patients with acute coronary syndrome in Thailand
2021, Journal of Cardiology
Citation Excerpt :
In addition, it is possible the rate of OMT at discharge was underestimated because data concerning OMT contraindication or drug intolerance were not collected. However, this bias is likely to have existed in previous studies as well [13, 14, 17, 19]. We do not know whether the patients took the prescribed drugs, as many patients had multiple comorbidities, and these medications are known to be associated with poor drug compliance.
Optimal medical therapy (OMT) is recommended for patients with acute coronary syndrome (ACS) at discharge. This study aimed to assess temporal trends of OMT prescription as a five-drug regimen at discharge and its association with clinical outcomes in patients with ACS in Thailand.
A retrospective cohort study was conducted in a tertiary-care medical center in Thailand. Data were collected from an electronic medical database. Patients were categorized into OMT or non-OMT groups based on their discharge medications. OMT was defined as a combination of aspirin and P2Y12 inhibitors, statins, beta-blockers, and angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers. The primary outcome was 1-year all-cause mortality. The secondary outcome was major adverse cardiac events (MACE) which was defined as a composite of non-fatal myocardial infarction, non-fatal stroke, and all-cause mortality. The prescription trends were also estimated. A multivariate Cox's proportional hazard model was used to assess the association of OMT prescriptions at discharge with all-cause mortality and MACE.
A total of 3531 patients discharged with ACS [mean age, 69.5 (SD 12.4) years; 58.3% male] were identified. Only 42.6% were discharged with OMT. The rates of OMT prescriptions did not change over time. However, the prescription of OMT with high-intensity statin was significantly increased from 5.0% in 2013 to 38.3% in 2018 (p for trend <0.001). Multivariable analyses indicated that OMT significantly reduced all-cause mortality (adjusted HR: 0.77; 95%CI: 0.63-0.95; p=0.012) and MACE (adjusted HR 0.84; 95%CI: 0.71-0.99; p = 0.044). Subgroup analysis indicated that patients receiving OMT with high-intensity statins exhibited survival benefits (adjusted HR: 0.72; 95%CI: 0.56-0.92; p=0.008).
The five-drugs comprising OMT were associated with a reduction in all-cause mortality and MACE in patients with ACS. Nevertheless, OMT prescribing remains underused and could be enhanced in the real-world setting.
Pharmacist role to enhance the prescribing of hospital discharge medications for patients after heart attack
2020, Saudi Pharmaceutical Journal
This study aimed to explore the cardiologist adherence with ACC/AHA guidelines on discharge medications for patients admitted with acute coronary syndrome (ACS), assess the predictors of cardiologist non-adherence and measure the impact of pharmacist intervention on improving guideline adherence.
The study included two consecutive phases: observation and intervention. It was carried out at Al-Najaf Center for Cardiac Surgery and Catheterization, Iraq, from August through December 2018. In the observation phase, medical records were reviewed retrospectively in order to assess the adherence to guideline. The intervention phase was performed prospectively by the clinical pharmacist, who conducted interventions including auditing, feedback and discussion with every prescriber. The reference of the recommendations was the guideline of American Heart Association/American College of Cardiology guideline (AHA/ACC). The primary outcome was the proportion of patients discharged with optimal treatment. Independent T-test was used to measure the difference in the means of age between the two patient groups. For categorical variables (gender, diagnosis, and comorbidities), chi-square test was used. Binary logistic regression was used to identify patient and disease characteristics associated with receiving optimal discharge regimen.
The observation phase included 100 patients with ACS, while the intervention phase included 105 patients. A total of 50 interventions were performed by pharmacist, of which adding necessary medication was the most frequent (88%), followed by dose optimization (10%), and removing medication duplication (2%). Seventy-four percent of the provided recommendations were accepted by the cardiologists. Pharmacist intervention caused significant (P-value < 0.05) improvement (increasing) in the prescribing of β-blockers, ACE inhibitors/ARBs, statins, and the proportion of patients who received all optimal five therapies (from 35% in observation phase to 80% after intervention).
This study showed that pharmacist intervention had a considerable positive impact on the cardiologist prescribing pattern of the essential discharge medications for patients with ACS which could improve patient clinical outcomes.
Unplanned 30-Day Readmission after Coronary Artery Bypass in Patients with Acute Myocardial Infarction
2020, Cardiovascular Revascularization Medicine
The Centers for Medicare and Medicaid services penalizes hospitals with higher than expected readmissions for coronary artery bypass graft surgery (CABG). Little information exists regarding outcomes in patients who sustain an acute myocardial infarction (MI) and undergo CABG as the primary revascularization strategy. Our goal was to determine the unplanned 30-day readmission rate in this high-risk population and predictors of readmission.
An institutional database was queried to identify patients from 2011 to 2017 who were admitted with an acute MI and underwent CABG within 30 days. Chart review was performed to collect demographics, medical comorbidities and clinical information related to hospital course and readmission status.
A total of 150 patients were included. The 30-day unplanned readmission rate was 23%, and the majority (80%) were non-cardiac related. Predictors of unplanned readmission included female sex (OR 2.61, 95% CI 1.042–6.549, p = 0.041), CABG performed <7 days following MI (OR 2.82, 95% CI 1.21–6.59, p = 0.017), and post-operative atrial fibrillation (OR 3.25, 95% CI 1.07–9.87, p = 0.038). Complications were identified in 32% of clinic visits in patients who did not require readmission.
Patients who undergo CABG following MI are a high-risk population with nearly one-quarter readmitted within 30 days. Female sex, <7 days between the index MI and CABG, and post-operative atrial fibrillation are strong predictors for readmission. Early outpatient follow-up may be an effective intervention to reduce hospital readmissions by reassuring patients that non-cardiac symptoms are in line with anticipated post-operative pain and healing.
Impact of Optimal Medical Therapy at Discharge on One-year Direct Medical Costs in Patients with Acute Coronary Syndromes: A Retrospective, Observational Database Analysis in China
2019, Clinical Therapeutics
This study was conducted to examine the use of optimal medical therapy (OMT), consisting of an antiplatelet, a β-blocker, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), and a statin combined, after hospital discharge and its relationship with direct medical costs in patients with acute coronary syndromes (ACS) in Tianjin, China.
Data were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2011–2015). Data from adult patients with ≥1 hospitalization for ACS between January 2012 and December 2014 were included. Medications including antiplatelets, β-blockers, ACEIs/ARBs, and statins at discharge were recorded, with OMT defined as the use of all 4 indicated medications. Propensity-score matching was conducted to form matched OMT and non-OMT cohorts based on baseline differences. All-cause and ACS-related health care resource utilization and direct medical costs during a 12-month follow-up period were assessed and compared between cohorts. Generalized linear modeling was conducted to assess the association between OMT at discharge and direct medical costs.
A total of 22,041 patients were identified (mean age, 64.7 [10.7] years; 45.6% female), of whom 15.1% (3336) received OMT at discharge. The OMT cohort had fewer patients hospitalized for any cause during follow-up compared with the matched non-OMT cohort (38.1% vs 43.2%; P < 0.001), which was further associated with fewer hospitalizations (1.55 vs 1.64; P = 0.019) and shorter annualized length of stay (15.9 vs 17.2 d; P = 0.041). Despite higher costs of outpatient services (9958 vs 10,060 Chinese yuan [CNY] [P = 0.006]; adjusted difference, +456 CNY [P = 0.004]) (year-2014 1 USD = 6.20 CNY), the OMT cohort had significantly lower all-cause total costs (20,771 vs 22,877 CNY [P = 0.174]; adjusted difference, –2089 CNY [P = 0.006]), driven by lower costs of inpatient services (10,813 vs 12,817 CNY [P < 0.001]; adjusted difference, –2184 CNY [P = 0.001]). The difference in ACS-related total costs between the 2 cohorts was not statistically significant (8535 vs 9304 CNY [P = 0.128]; adjusted difference, –558 CNY [P = 0.214]).
Receiving OMT at discharge was associated with fewer hospitalizations and lower all-cause direct medical costs in these patients with ACS in China. Strategies are needed to improve OMT prescribing rates at discharge, which would lead to better clinical prognosis and total cost-savings among patients with ACS in China.

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: The Canadian ACS Registries were sponsored by the Canadian Heart Research Centre (a federally incorporated not-for-profit academic research organization) and Key Pharmaceuticals, Division of Schering Canada Inc (ACS I), Pfizer Canada Inc (ACS II), Sanofi Aventis Canada Inc (ACS II), and Bristol-Myers Squibb Canada Inc (ACS II). The industrial sponsors had no involvement in the study conception or design; in the collection, analysis, and interpretation of data; in the writing, review, or approval of the manuscript; and in the decision to submit the manuscript for publication.

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Clinical InvestigationsAcute Ischemic Heart DiseaseOptimal medical therapy at discharge in patients with acute coronary syndromes: Temporal changes, characteristics, and 1-year outcome

Background

Methods

Results

Conclusions

Section snippets

Study design and patient population

Results

Discussion

Conclusion

J Am Coll Cardiol

Am Heart J

Am J Med

Am J Med

Am Heart J

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

Am J Med

Am Heart J

J Am Coll Cardiol

Am Heart J

Lancet

Can J Cardiol

J Am Coll Cardiol

Am J Med

Temporal changes in the outcomes of acute myocardial infarction in Ontario, 1992-1996

CMAJ

Clinical Investigations
Acute Ischemic Heart Disease
Optimal medical therapy at discharge in patients with acute coronary syndromes: Temporal changes, characteristics, and 1-year outcome