Longitudinal persistence with secondary prevention therapies relative to patient risk after myocardial infarction

• Type of Material: Article
• Authors: Supriya Shore, Emory University; Philip G. Jones, St Lukes Mid America Heart Institute; Thomas M. Maddox, University of Colorado; Steven M. Bradley, University of Colorado; Joshua M. Stolker, St. Louis University; Suzanne V. Arnold, St Lukes Mid America Heart Institute; Susmita Parashar, Emory University; Pamela Peterson, University of Colorado; Deepak L. Bhatt, Harvard University; John Spertus, St Lukes Mid America Heart Institute; P. Michael Ho, University of Colorado
• Language: English
• Date: 2015-05-15
• Publisher: BMJ Publishing Group
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2015 BMJ Publishing Group Ltd & British Cardiovascular Society.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1136/heartjnl-2014-306754
• Title of Journal or Parent Work: Heart
• Volume: 101
• Issue: 10
• Start Page: 800
• End Page: 807
• Grant/Funding Information: PREMIER was sponsored by CV Therapeutics Inc, Palo Alto, CA.; TRIUMPH was supported by a grant from the National Institutes of Health (National Heart, Lung, Blood Institute): Washington University School of Medicine [SCCOR Grant #P50HL077113-01].
• Keywords: Prescription; Nonadherence; Drug therapy; Disease; Guideline adherence; Registry; Science & Technology; Outcomes; Medication; Acute coronary syndrome; American Heart Association; Cardiovascular System & Cardiology; Life Sciences & Biomedicine; Cardiac & Cardiovascular Systems
• Research Categories: Health Sciences, Rehabilitation and Therapy; Health Sciences, Occupational Health and Safety; Engineering, Biomedical; Health Sciences, Pharmacy

Abstract

Background: Prior studies have demonstrated that patients with high-risk acute myocardial infarction (AMI) are less likely to receive guideline-directed medications during hospitalisation. It is unknown if this paradox persists following discharge. We aimed to assess if persistence with guideline-directed medications post discharge varies by patients' risk following AMI. Methods: Data were analysed from two prospective, multicentre US AMI registries. The primary outcome was persistence with all prescribed guideline-directed medications (aspirin, ß-blockers, statins, angiotensin-antagonists) at 1, 6 and 12 months post discharge. The association between risk and medication persistence post discharge was assessed using multivariable mixed-effect models. Results: Among 6434 patients with AMI discharged home, 2824 were considered low-risk, 2014 intermediate-risk and 1596 high-risk for death based upon their Global Registry of Acute Coronary Event (GRACE) 6-month risk score. High-risk was associated with a lower likelihood of receiving all appropriate therapies at discharge compared with low-risk patients (relative risk (RR) 0.90; 95% CI 0.87 to 0.94). At 12 months, the rate of persistence with all prescribed therapies was 61.5%, 57.9% and 45.9% among low-risk, intermediate-risk and high-risk patients, respectively. After multivariable adjustment, high-risk was associated with lower persistence with all prescribed medications (RR 0.87; 95% CI 0.82 to 0.92) over follow-up. Similar associations were seen for individual medications. Over the 5 years of the study, persistence with prescribed therapies post discharge improved modestly among high-risk patients (RR 1.05; 95% CI 1.03 to 1.08 per year). Conclusions: High-risk patients with AMI have a lower likelihood of persistently taking prescribed medications post discharge as compared with low-risk patients. Continued efforts are needed to improve the use of guideline-directed medications in high-risk patients.