Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes

Abstract

Background Optimal secondary prevention pharmacotherapy is the cornerstone of post‐acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline‐recommended therapies is poorly described. Aim To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors. Methods Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near‐optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long‐term mortality. Cox‐proportional hazard modelling was undertaken to assess independent predictors of survival. Results Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P < 0.01 for all). SMT was associated with higher long‐term mortality at 3.9 ± 2.2 years when compared to NMT and OMT (16.8% vs 10.5% vs 8.2%, P < 0.001). Compared to OMT, SMT was an independent predictor of long‐term mortality (hazard ratio, HR 1.62, 95% confidence interval, CI 1.30–2.02, P < 0.01) while NMT was associated with a clinically significant 14% mortality hazard (HR 1.14, 95% CI 0.97–1.34, P = 0.11). Conclusions There is a graded long‐term hazard associated with not receiving OMT after an ACS. Improvements in secondary prevention pharmacotherapy models of care are warranted to further decrease the long‐term mortality.

Assessing optimal medical therapy adherence following acute coronary syndrome utilising telehealth cardiology pharmacist clinics

“…Age strati cation at time of percutaneous coronary intervention (PCI) [ Based on previous studies, adherence to medications at twelve months post ACS event can vary between 45-75%. [3,7] Based on a population size of approximately 100 patients to have ACS in the seven-month (January 2020 to July 2020) intervention period, with an alpha of 0.05 and beta of 0.2, the sample size would need to be 73-78 matched patient pairs. For outcome calculations, McNemar's chi-squared analysis for matched data was used between the control and intervention pairs.…”

“…When considering OMT's ability to reduce MACE, signs of bene t are not fully detected until after twelve months in this setting. [3] When extrapolated to the 250 patients who receive PCI for ACS per year, this service appears to prevent 52 admissions per year when compared to the population before the telehealth cardiology pharmacist clinic commenced; based on average admission cost of $5,205, this equates to $270,600 per year in admission savings. [21] However, further exploration of the effects of the clinic and the type of admissions prevented is required to con rm this.…”

“…[3] However, medications remain the mainstay of treatment for secondary prevention of subsequent ACS events. [3][4][5] In particular, there are a number of medications directly linked with mortality bene t and reduction of MACE (major adverse cardiovascular events). These medications are referred to as optimal medication therapy (OMT) and consist of four groups: Dual anti-antiplatelet therapy, which includes aspirin and a P2Y12 inhibitor (clopidogrel, prasugrel, or ticagrelor), HMG Co-A reductase inhibitors (statins), beta blockers, and angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB).…”

“…(8.2% vs. 16.8%, p < 0.001, n = 9,375). [3] There are a multitude of factors associated with poor medication adherence, such as socioeconomic status, age, and health literacy. [9,10] Poor understanding of medications is a contributor to poor medication adherence, illustrating the importance of providing appropriate medication and disease education to patients.…”

Role of renin–angiotensin system antagonists on long-term mortality post-percutaneous coronary intervention in reduced and preserved ejection fraction

“…Optimal medical therapy plays a critical role in preventing further cardiovascular events and improving clinical outcomes following percutaneous coronary intervention (PCI) for ACS [1][2][3]. As such, international guidelines recommend multiple medications for secondary-prevention including anti-platelet agents, a β-adrenergic receptor blocker (β-blocker), and a statin [4][5][6][7].…”