Systematic underutilisation of secondary preventive drugs in patients with acute coronary syndrome and reduced renal function

Abstract

Aims The high risk of recurrent events in patients with reduced renal function following an acute coronary syndrome (ACS) may in part be due to suboptimal secondary prevention. We aimed to describe the association between renal dysfunction and the prescription, initiation and persistent use of secondary prevention during the first year after a first ACS. Methods We identified all patients admitted to any Swedish coronary care unit for a first ACS between 2005 and 2010 ( n = 77,432). In 75,129 patients, creatinine levels were available in order to obtain the estimated glomerular filtration rate (eGFR). Persistent use of prescribed drugs was determined for 1 year using the National Prescription Registry, with complete coverage of all prescribed and dispensed drugs in Sweden. Results After adjustment for relative and absolute contraindications, compared to patients with eGFR ≥ 60 mL/min/1.73 m, patients with eGFR 30-59 had higher odds of not being prescribed acetylsalicylic acid (ASA; odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.47-1.67), statins (OR: 2.94, 95% CI: 2.86-3.13) or β-blockade (OR: 1.25, 95% CI: 1.18-1.32). Patients with eGFR 30-59 were more likely to discontinue treatment with ASA (hazard ratio [HR]: 1.59, 95% CI: 1.42-1.56), statins (HR: 1.35, 95% CI: 1.29-1.41), angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (HR: 1.37, 95% CI: 1.31-1.43) or β-blockade (HR: 1.22, 95% CI: 1.18-1.27). Patients with eGFR < 30 showed a similar pattern in both prescription and discontinuation. Conclusion High-risk ACS patients with reduced renal function are less likely to be prescribed secondary prevention drugs at discharge, are less likely to initiate treatment when being prescribed these drugs, are less likely to be persistent in the use of these drugs and more often discontinue treatment.

Risk of mortality and recurrent cardiovascular events in patients with acute coronary syndromes on high intensity statin treatment

“…There are a number of explanations for the relatively low use of statin: statins may not be prescribed by primary doctor (for example, due to previous side effects) or statins may be prescribed but not picked up, which has been recently shown to be a major phenomenon among Swedish ACS patients with poor kidney function (Khedri et al, 2017). …”

Increased concentrations of platelet- and endothelial-derived microparticles in patients with myocardial infarction and reduced renal function- a descriptive study

“…At the same time as CKD patients have a high risk of thrombotic events, they also have an increased risk of bleeding [11]. This may in part explain why CKD patients are less likely to receive early revascularisation when they have an AMI, and receive less evidence based secondary prevention treatment [12, 13].…”

Impact of acetylsalicylic acid on primary prevention of cardiovascular diseases: A meta-analysis of randomized trials

“…Individual risk of bleeding and cardiovascular death needs to be taken into consideration before prescribing ASA, to avoid possible overuse or underuse. 20–24 We recommend that practitioners take limitations into account while interpreting the results of our study. Lack of individual participant data, and variation in inclusion criteria among included studies are some of the limitations of our study.…”