Impact of Combination Evidence‐Based Medical Therapy on Mortality Following Myocardial Infarction in Elderly Patients

Tay, Edgar; Chan, Mark Y.; Tan, Virlynn; Sim, Ling Ling; Tan, Huay‐Cheem; Cheng, Yeo Tiong

doi:10.1111/j.1076-7460.2007.07242.x

Cited by 12 publications

(20 citation statements)

References 15 publications

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“…However, these studies are likely to be confounded by healthy user bias and are too small to answer the question of comparative effectiveness of specific drug combinations, with most enrolling fewer than 6000 patients. [397][398][399][400][401] The MINAP registry is substantially larger and has provided, for the first time, the opportunity to evaluate the comparative effectiveness of aspirin, clopidogrel, beta-blockers, ACEIs and statins individually and in all combinations.…”

Section: Introductionmentioning

confidence: 99%

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

Hemingway

Feder

Denaxas

et al. 2017

Programme Grants Appl Res

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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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Section: Introductionmentioning

confidence: 99%

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

Hemingway

Feder

Denaxas

et al. 2017

Programme Grants Appl Res

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“…In conseguenza le linee guida raccomandano l'utilizzo routinario di questi farmaci [1][2][3]. Infatti, Goldberg et al [4], usando i dati dello studio GRACE (Global Registy of Acute Coronary Events), su 26.413 pazienti senza controindicazioni alla loro assunzione, hanno rilevato, dopo l'implementazione delle linee guida, un deciso aumento dal 2000 al 2005 nell'assunzione di statine (dal 45% al 85%), ACE-I (dal 63% al 77%), betabloccanti (al 83% al 91%) e ASA (circa 95%).…”

Section: Introduzioneunclassified

The challenge of improving evidence-based therapy adherence in the secondary prevention of coronary artery disease: the next frontier of cardiac rehabilitation

Scardi

Mazzone²,

Umari

2016

Monaldi Arch Chest Dis

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EDITORIALE IntroduzioneMolti studi randomizzati e controllati hanno definitivamente dimostrato l'efficacia dell'uso di acido acetilsalicilico (ASA), betabloccanti, ACE-inibitori (ACE-I) e statine per la prevenzione secondaria nei pazienti con cardiopatia ischemica. In conseguenza le linee guida raccomandano l'utilizzo routinario di questi farmaci [1][2][3]. Infatti, Goldberg et al. [4], usando i dati dello studio GRACE (Global Registy of Acute Coronary Events), su 26.413 pazienti senza controindicazioni alla loro assunzione, hanno rilevato, dopo l'implementazione delle linee guida, un deciso aumento dal 2000 al 2005 nell'assunzione di statine (dal 45% al 85%), ACE-I (dal 63% al 77%), betabloccanti (al 83% al 91%) e ASA (circa 95%).Nonostante i dimostrati benefici la terapia cardioprotettiva però è poco utilizzata per la scarsa aderenza dei pazienti: infatti il 20-50% risulta non aderente alla terapia medica cronica [5][6].L'aderenza alla terapia è la percentuale di farmaci e delle loro dosi, prescritte dai medici curanti, che i pazienti devono assumere con la stabilita frequenza e per un preciso periodo di tempo. A differenza della compliance (grado con cui il comportamento passivo di un paziente coincide con le raccomandazioni del medico), l'aderenza prevede il coinvolgimento attivo e collaborativo del paziente a cui si chiede di partecipare alla pianificazione e all'attuazione di un trattamento elaborando un consenso basato sull'accordo [7].L'aderenza è un fenomeno complesso che riflette l'interfaccia tra efficacia, tollerabilità, frequenza di somministrazione, interazioni fra preparati, effetti indesiderati e costi di eventuali tickets [8]. Nell'aderenza alla terapia è necessario rilevare anche il dosaggio dei farmaci assunti per il raggiungimento del target, perché solo in questo modo si ottengono benefici [2]. Gli aderenti alla terapia poi sono aderenti spesso anche alle modificazioni dello stile di vita [9].La prevenzione secondaria della cardiopatia ischemica è difficile a causa della politerapia (almeno 3-4 farmaci al giorno) che comporta regimi complessi con prescrizioni multiple e pluralità di somministrazioni in ore differenti della giornata. Ciò Migliorare l'aderenza all'assunzione dei farmaci per la prevenzione secondaria della cardiopatia ischemica: la prossima frontiera della riabilitazione cardiovascolare ABSTRACT:The challenge of improving evidence-based therapy adherence in the secondary prevention of coronary artery disease: the next frontier of cardiac rehabilitation. S. Scardi, C. Mazzone, P. Umari. Non-adherence to prescribed drug regimens is an increasing medical problem affecting physicians and patients and contribute to negative outcomes, such as the increased risk of subsequent cardiovascular events. Analysis of various patient populations shows that the choice of drug, its tolerability and the duration of treatment influence the non-adherence. Intervention is required toward patients and health-care providers to improve medication adherence. This review deals about the prevalence of n...

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“…Over the past several decades, advances in the medical treatment of coronary heart disease have resulted in a significant decline in hospital and short‐term mortality . Numerous clinical trials have demonstrated the efficacy of 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase inhibitors (statins), beta‐blockers (BBs), angiotensin‐converting enzyme inhibitors (ACEIs), angiotensin‐II receptor blockers (ARBs), and antiplatelet agents such as clopidogrel for secondary prevention in individuals who have had an AMI . Use of these evidence‐based medications is now a cornerstone of long‐term medical therapy in this population…”

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confidence: 99%

Effect of Exposure to Evidence‐Based Pharmacotherapy on Outcomes After Acute Myocardial Infarction in Older Adults

Zuckerman

Yin

Rattinger

et al. 2012

J American Geriatrics Society

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Objectives To assess the impact of exposure to evidence-based medication following hospital discharge for Medicare beneficiaries with acute myocardial infarction (AMI). Design A discrete-time hazard model was used to estimate time-to-outcome associated with exposure to four drug classes (angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers (BBs), statins, and clopidogrel) used for post-AMI secondary prevention of cardiovascular events and mortality. Setting Medicare administrative data for a 5% random sample of beneficiaries. Participants Medicare beneficiaries (n=9,538) hospitalized for an AMI between 4/1/2006 and 12/31/2007 who survived for at least 30 days after discharge. The cohort was followed until death or 12/31/2008. Measurements Time-varying exposure was measured as proportion of days covered (PDC) for each quarter during the follow-up period. PDC was classified into five categories (0–0.2; >0.2–0.4; >0.4–0.6; >0.6–0.8; >0.8–1.0). Outcomes were mortality and a composite outcome of death or post-AMI hospitalization. Results Over a median follow-up of 18 months, mean PDC rates ranged from 0.37 (clopidogrel) to 0.50 (statins). When comparing the highest versus lowest categories of exposure, the hazard of the composite outcome was significantly lower for all drug classes except BBs [statins, adjusted hazard ratio (aHR) = 0.71, ACEIs/ARBs, aHR = 0.81, clopidogrel, aHR = 0.85, BBs, aHR = 0.93]. All four drug classes were significantly associated with reductions in mortality; the magnitude of effect for the mortality outcome was largest for statins and smallest for BBs. Age modified the effect of statins on mortality. Conclusion Use of evidence-based medications for secondary prevention post-AMI is suboptimal in the Medicare population and low exposure rates are associated with significantly higher risk for subsequent hospitalization and death.

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Impact of Combination Evidence‐Based Medical Therapy on Mortality Following Myocardial Infarction in Elderly Patients

Cited by 12 publications

References 15 publications

The challenge of improving evidence-based therapy adherence in the secondary prevention of coronary artery disease: the next frontier of cardiac rehabilitation

Effect of Exposure to Evidence‐Based Pharmacotherapy on Outcomes After Acute Myocardial Infarction in Older Adults

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