Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes

Real-world management of hypercholesterolemia in patients after acute coronary syndrome in Greece

Background

Prompt initiation of lipid-lowering therapy (LLT) following acute coronary syndrome (ACS) is crucial for preventing secondary cardiovascular events. However, there are gaps in clinical implementation of the 2019 ESC/EAS guideline-recommended low-density lipoprotein cholesterol (LDL-C) goal of <55 mg/dL in patients post-ACS.

Methods

This multicenter, real-world, retrospective, 12-month study of adult patients in Greece hospitalized for ACS from September 2019 to November 2022 assessed the attainment of target LDL-C (<55 mg/dL) during the first year post-ACS. Eligible patients had elevated LDL-C at hospitalization (>130 mg/dL if LLT naïve; >100 mg/dL if on statin monotherapy; >70 mg/dL if on a statin plus ezetimibe) and ≥1 LDL-C measurement within 12 months post-ACS.

Results

Overall, 212 eligible patients of mean (SD) age 59.9 (±11.1) years were enrolled. Type 2 diabetes and hypertension were reported in 19.8 % (42/212) and 50.9 % (108/212) of patients, respectively. Median (Q1, Q3) LDL-C was 138.0 (106.5, 158.0) mg/dL at hospitalization (n = 212). In patients with LDL-C availability at 12 months posthospitalization (n = 197), median (Q1, Q3) LDL-C was 64.0 (53.0, 76.0) mg/dL, with 27.9 % of patients (55/197) attaining LDL-C <55 mg/dL. Although 73.9 % of patients (199/212) were discharged from the hospital on statin monotherapy, 50 % of patients (106/212) were receiving statin-ezetimibe LLT and 1.4 % (3/212) were receiving statin-ezetimibe-PCSK9 inhibitor LLT 12 months posthospitalization.

Conclusion

LDL-C goal attainment is suboptimal in the first year after ACS hospitalization in Greece, indicating an unmet need to improve the treatment of patients with hypercholesterolemia during the post-ACS period by optimizing lipid management through earlier LLT intensification.

Optimal medical therapy, clinical outcome and its predictors in patients with acute coronary syndrome after discharge with secondary prevention medications at University of Gondar Comprehensive Specialized Hospital, North West Ethiopia, 2023: A retrospective follow-up study

BACKGROUND

The life-threatening diseases known as ACS (acute coronary syndrome) continue to produce considerable rates of morbidity and mortality despite breakthroughs in therapy. The study determined clinical outcome and its predictors in patients at the University of Gondar Comprehensive and Specialized Hospital (UOGCSH), North West Ethiopia.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study design was employed at UOGCSH from January 31, 2018 to February 1, 2023. The hospital used a systematic random sampling procedure to select study participants from the medical records of patients in chronic cardiac follow-up clinics.

MAIN OUTCOME MEASURES

Exposures were optimal medical therapy (OMT) versus non-optimal medical therapy collected from May to August 2023. Descriptive and analytical statistics were employed to compare study groups. A binary logistic regression model was employed to identify candidate variables for further analysis. Cox's proportional hazard model and log-rank test were employed, with a P-value < 0.05 used to evaluate statistical significance. A five-year all-cause mortality after discharge estimate was displayed by using Kaplan-Meier curves.

RESULTS

Among 422 patients with ACS [mean age, 61.56 (SD = 9.686) years; 54.7% male], of whom only 59.2% (250) received optimal medical therapy at discharge. Age ≥ 65, atrial fibrillation, chronic kidney diseases, and cardiogenic shock were negative independent predictors of optimal medical therapy. On the other hand, male sex was independently associated with the use of optimal medical therapy. All-cause mortality occurred in 16.6% (n = 70) and major adverse cardiac events occurred in 30.8% (n = 130) of patients with a 95% CI of 0.132-0.205 and 0.264-0.355, respectively. Multivariate analyses indicated that OMT was significantly associated with reduced all-cause mortality (aHR: 0.431, 95% CI: 0.222-0.835; P = 0.013).

CONCLUSION

This study revealed that the use of preventive OMT in patients discharged with acute coronary syndrome was associated with a reduction in all-cause mortality. However, the use of this OMT is suboptimal.

Patterns of 12-Month Post-Myocardial Infarction Medication Use According to Revascularisation Strategy: Analysis of 15,339 Admissions in Victoria, Australia

AIM

Clinical guidelines recommend secondary prevention medications following myocardial infarction (MI) regardless of revascularisation strategy. Studies suggest that there is variation in post-MI medication use following percutaneous coronary intervention (PCI) and coronary artery bypass grafts (CABG). We investigated initial dispensing and 12-month patterns of medication use according to revascularisation strategy following non-ST-elevation MI (NSTEMI).

METHOD

We included all public and private hospital admissions for NSTEMI for patients aged ≥30 years in Victoria, Australia, between July 2012 and June 2017. We investigated initial dispensing of P2Y12 inhibitors (P2Y12i), statins (total and high intensity), angiotensin-converting-enzyme inhibitors (ACEi)/angiotensin receptor blockers (ARB), and beta blockers within 60 days after discharge. Twelve-month post-MI medication use was estimated as the proportion of days covered (PDC) over a 12-month period from the date of hospital discharge. Analyses were performed using adjusted regression models, stratified by revascularisation strategy.

RESULTS

There were 15,399 admissions for NSTEMI: 11,754 with PCI and 3,645 with CABG. Following adjustments, predicted probability of initial dispensing in the PCI and CABG groups, respectively, was 0.94 (95% confidence interval 0.93-0.95) vs 0.17 (0.13-0.21) for P2Y12i; 0.69 (0.66-0.71) vs 0.42 (0.37-0.48) for ACEi/ARB; 0.59 (0.57-0.62) vs 0.69 (0.64-0.74) for beta blockers; 0.89 (0.87-0.91) vs 0.89 (0.85-0.92) for statins; and 0.60 (0.57-0.62) vs 0.69 (0.63-0.73) for high intensity statins. The 12-month PDC in the PCI and CABG groups, respectively, was 0.82 (0.80-0.83) vs 0.12 (0.09-0.15) for P2Y12i; 0.62 (0.60-0.65) vs 0.43 (0.39-0.48) for ACEi/ARB; 0.53 (0.51-0.55) vs 0.632 (0.58-0.66) for beta blockers; 0.79 (0.78-0.81) vs 0.78 (0.74-0.81) for statins; and 0.49 (0.47-0.51) vs 0.55 (0.50-0.59) for high intensity statins.

CONCLUSIONS

Post-discharge dispensing of secondary prevention medications differed with respect to revascularisation strategy from 2012 to 2017, despite clear evidence of benefit during this period. Interventions may be needed to address possible clinician and patient uncertainty about the benefits of secondary prevention medications, regardless of revascularisation strategy.

Long-term secondary prevention and outcome following acute coronary syndrome: real-world results from the Swedish Primary Care Cardiovascular Database

AIMS

Most studies of treatment adherence after acute coronary syndrome (ACS) are based on prescribed drugs and lack long-term follow-up or consecutive data on risk factor control. We studied the long-term treatment adherence, risk factor control, and its association to recurrent ACS and death.

METHODS AND RESULTS

We retrospectively included 3765 patients (mean age 75 years, 40% women) with incident ACS from 1 January 2006 until 31 December 2010 from the Swedish Primary Care Cardiovascular Database of Skaraborg. All patients were followed until 31 December 2014 or death. We recorded blood pressure (BP), low-density lipoprotein cholesterol (LDL-C), recurrent ACS, and death. We used data on dispensed drugs to calculate the proportion of days covered for secondary prevention medications. Cox regressions were used to analyse the association of achieved BP and LDL-C to recurrent ACS and death. The median follow-up time was 4.8 years. The proportion of patients that reached BP of <140/90 mm Hg was 58% at Year 1 and 66% at Year 8. 65% of the patients reached LDL-C of <2.5 mmol/L at Year 1 and 56% at Year 8; however, adherence to statins varied from 43% to 60%. Only 62% of the patients had yearly measured BP, and only 28% yearly measured LDL-C. Systolic BP was not associated with a higher risk of recurrent ACS or death. Low-density lipoprotein cholesterol of 3.0 mmol/L was associated with a higher risk of recurrent ACS {hazard ratio [HR] 1.19 [95% confidence interval (CI) 1.00-1.40]} and death HR [1.26 (95% CI 1.08-1.47)] compared with an LDL-C of 1.8 mmol/L.

CONCLUSION

This observational long-term real-world study demonstrates low drug adherence and potential for improvement of risk factors after ACS. Furthermore, the study confirms that uncontrolled LDL-C is associated with adverse outcome even in this older population.

Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41,925 myocardial infarctions in Australia

BACKGROUND

People in remote areas may have more difficulty accessing healthcare following myocardial infarction (MI) than people in metropolitan areas. We determined whether remoteness was associated with initial and 12-month use of secondary prevention medications following MI in Victoria, Australia.

METHOD

We included all people alive at least 90 days post-discharge following MI between July 2012 and June 2017 in Victoria, Australia (n=41,925). We investigated dispensing of P2Y12 inhibitors (P2Y12i), statins, ACE-inhibitors or angiotensin receptor blockers (ACEI/ARBs), and beta-blockers within 90 days post-discharge. We estimated 12-month medication use using proportion of days covered (PDC). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). Data were analyzed using adjusted parametric regression models stratified by STEMI and NSTEMI.

RESULTS

There were 10,819 STEMI admissions and 31,106 NSTEMI admissions. Following adjustment across NSTEMI and STEMI, there were no medication classes dispensed in the 90-days post-discharge that differed in a clinically significant way from the least remote (ARIA=0) to the most remote (ARIA=4.8) areas. The largest difference for NSTEMI were ACEi/ARB, with 71%(95%CI 70-72%) versus 80%(76%-83%). For STEMI, it was statins with 89%(88-90%) versus 95%(91-97%). Predicted PDC for STEMI and NSTEMI were not clinically significant across remoteness, with the largest difference in NSTEMI being P2Y12i with 48%(47-50%) versus 55%(51-59%), and in STEMI it was ACEi/ARB with 68%(67-69%) versus 76%(70-80%).

CONCLUSION

Remoteness does not appear to be a clinically significant driver for medication use following MI. Possible differences in cardiovascular outcomes in metropolitan and non-metropolitan areas are not likely to be explained by access to secondary prevention medications.

Optimising adherence to secondary prevention medications following acute coronary syndrome utilising telehealth cardiology pharmacist clinics: a matched cohort study

BACKGROUND

Adherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally.

AIM

To explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS.

METHOD

Retrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records.

RESULTS

There were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004).

CONCLUSION

This novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.

Clinical outcome measures in the assessment of impact of pharmacists in cardiology ambulatory care: A systematic review

AIMS

Pharmacists are involved in the care of patients with cardiac disease within the ambulatory setting across multiple modes of delivery and practice settings. There is a lack of consensus surrounding the assessments used to measure the impact of pharmacist care. This heterogeneity may undermine confidence and limit utilisation of pharmacists in cardiology ambulatory care. A systematic review was conducted to understand how pharmacist interventions in cardiology ambulatory care were assessed and the impacts of these interventions on patient-centred outcomes.

METHODS AND RESULTS

A comprehensive search was conducted of MEDLINE, CINAHL Plus, Cochrane Register of Randomised Controlled Trials and EMBASE from 2000 to 2020 with search terms involving pharmacist interventions among cardiology patients in the ambulatory care setting; with studies restricted to randomised controlled trials. Search results were independently screened by two reviewers. The Cochrane Risk of Bias in Randomised Trials tool was used for quality assessment of the included studies. Assessments of pharmacist impact were analysed and compared to established quality indicators of cardiology care. The search produced 3380 individual studies, following screening, 26 studies involving 9013 participants met inclusion criteria. Across the 26 included studies, eleven different intervention types were identified. Four main outcome measures assessing the impact of these interventions were identified: direct measure of cardiovascular disease risk factor, major adverse cardiovascular events, medication adherence, validated risk score for cardiovascular events. There was a high degree of variance in both the way these interventions influenced the outcome as well the outcome measures selected to assess the impact of the intervention. Of the 26 studies, sixteen listed positive impacts on primary outcomes and the remaining 10 listed neutral effects.

CONCLUSION

Several outcome measures have been used to assess the impact of pharmacist intervention in cardiology ambulatory care. Aligning outcome measures with known indicators of cardiology care quality, as well as more detailed descriptions of intervention, will provide clinicians vital information in designing effective and measurable interventions in cardiology ambulatory care.

The Diagnostic Value of Combined Detection of Serum Lp-PLA2 and Hcy and Color Doppler in Elderly Patients with Acute Coronary Syndrome and Effect on Endothelial Function

Objective

To evaluate the application value of serum lipoprotein-associated phospholipase A2 (Lp-PLA2) and homocysteine (Hcy) combined with color Doppler detection in elderly patients with acute coronary syndrome (ACS) and the influence on their endothelial function.

Methods

From February 2019 to October 2020, 100 elderly patients with suspected ACS treated in our hospital were recruited and assigned (1 : 1) to a control group or an experimental group. The control group received color Doppler detection, and the experimental group received the combined detection of serum Lp-PLA2 and Hcy and color Doppler. Positive results were determined by the combined detection of the levels of LP-PLA2 and Hcy and color Doppler. The two groups were compared in terms of specificity, susceptibility, positive detection rate, negative detection rate, test accuracy, the area under the receiver operating characteristic (ROC) curve (AUC), the expression levels of interleukin-2 (IL-2), interleukin-12 (IL-12), interleukin-13 (IL-13), and the vascular endothelial function. The patients with ACS were divided into three subgroups according to the Gensini score three-quartile interval, and their Lp-PLA2 levels were calculated for analysis.

Results

The test specificity, susceptibility, positive detection rate, negative detection rate, test accuracy, and AUC in the experimental group were much better than the those in the control group (all P < 0.05), and there were no significant differences in the expression levels of IL-2, IL-12, IL-13, and vascular endothelial function between the two groups (P > 0.05). The three subgroups showed similar levels of fasting blood glucose, total cholesterol, triglyceride, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol, apolipoprotein A-I, glutamic-pyruvic transaminase, lutamic-oxaloacetic transaminase, homocysteine, and amino-terminal pro-brain natriuretic peptide (all P > 0.05). The severe condition group had the highest Lp-PLA2 level, followed by the moderate group, and then the mild group (P < 0.05). Moreover, the levels of LP-PLA2, aspartate transaminase (AST), and N-terminal pro hormone B-type natriuretic peptide (NT-proBNP) were all influencing factors for the coronary Gensini score (all P < 0.05).

Conclusion

The combined detection of serum Lp-PLA2, Hcy, and color Doppler significantly improves the diagnostic accuracy, specificity, and susceptibility in the elderly with ACS, with little impact on their vascular endothelial function.

Changes in Long-term Mortality in Patients with Myocardial Infarction History According to the LIS Luberetskiy registry

Aim. The aim of the research was to study the dynamics of distant cases of the disease that underwent AMI in 2005-2007 (LIS registry) and in 2014 and 2018 (LIS-3 registry), discharged from the same hospital of the Lyubertsy District Hospital (LDH).Material and methods. The study was conducted on the basis of two registries - a retrospective-prospective register LIS (Lyubertsy investigation of death), which was conducted in the Lyubertsy district of the Moscow region, all cases of check-ups in the AMI hospital for a 3-year period (2005- 2007) and the prospective register LIS-3 (11/01/2013 – to the present), which included patients admitted to the cardiology department of the Lyubertsy District Hospital No. 2 with the correct diagnosis of Acute coronary syndrome with and without ST segment elevation. With patients discharged from the hospital, a telephone contact was established no earlier than 1 year after discharge to clarify the life status, and in case of death – to find out its causes. Search for patients who did not answer the phone call, was using by the study of the archive of the polyclinic, with database statistics. Longterm cases of the LIS were compared with LIS-3 registers, clinical demographic characteristics and risk indicators in patients in the LIS and LIS-3 registers were also compared, differences in drug therapy before the onset of AMI and after discharge from the hospital register between LIS and LIS3 were analyzed.Results. Out of 327 patients, the registry included 104 (31.8%) patients discharged in 2014 and 223 (68.2%) in 2018. When comparing the longterm mortality curves of the LIS and LOS-3 registers, a significant difference was noted. The LIS-3 study revealed more frequent referrals for antiplatelet agents (20% vs 16%), statins (11.6% vs 2.0%). Less commonly, diuretics began to be prescribed at the prehospital level. After discharge from the hospital in the LIS-3 registry, a decrease compared to the LIS registry, more frequent prescription of antiplatelet agents (97.5% vs 85.0%), anticoagulants (1.1% vs 0%), statins (96.5% vs 67.0%), beta-blockers (93.3% vs 81.0%). Less commonly, diuretics are prescribed at discharge from the hospital.Conclusion. The present study of the LIS-3 registry showed a significant decrease in the incidence of those who had AMI, which occurred 15-20 years after the LIS registry was conducted.

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

AIMS

The use of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II-receptor blockers (ARBs) post-myocardial infarction (MI) is supported by evidence based on trials performed in the thrombolysis era. This was prior to primary percutaneous coronary intervention (PCI) being routine practice, and with little direct evidence for the use of these medications in patients with preserved left ventricular (LV) function. This study sought to determine whether there is an association between ACEi/ARB use after PCI for acute coronary syndrome (ACS) and long-term all-cause mortality, with a particular focus on patients with preserved LV function.

METHODS

This multicentre, observational study evaluated prospectively collected data of 21,388 patients (> 18 years old) that underwent PCI for NSTEMI and STEMI between 2005 and 2018, and were alive at 30 day follow-up.

RESULTS

In total, 83.8% of patients were using ACEi/ARBs. Kaplan-Meier analysis demonstrated ACEi/ARB use was associated with a significantly lower mortality in the entire cohort (15.0 vs. 22.7%; p < 0.001) with a mean follow-up of 5.58 years; and independently associated with 24% lower mortality by Cox proportional hazards modelling (HR 0.76, CI 0.67-0.85, p < 0.001). ACEi/ARB therapy was also associated with significantly lower mortality in patients with reduced or preserved LV function, with greater survival benefit with worse LV dysfunction.

CONCLUSION

ACEi/ARB therapy post-PCI is associated with significantly lower long-term mortality in patients with reduced and preserved LV function. These findings provide contemporary evidence for using these agents in the current era of routine primary PCI, including those with preserved EF.