Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After AMI

Study Questions:

What are patterns of medication prescription and dosing of secondary prevention medications at both hospital discharge and outpatient follow-up after acute myocardial infarction (AMI)?

Methods:

This was a post-hoc analysis of patients enrolled in either the PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) study or the TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health status) study. The primary outcome was whether a patient reported taking a goal dose of beta-blocker, statin, and angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB) at 12 months after AMI. Prescribed doses were categorized as none, low (<50% target), moderate (50-74% target), or goal (≥75% target).

Results:

At hospital discharge, most eligible patients were prescribed some dose of each medication: beta-blockers, 93%; statins, 88%; and ACE inhibitor/ARB, 88%. Twelve months after AMI, only 60-70% of patients reported taking any dose of beta-blocker, statin, or ACE inhibitor/ARB. At 12 months after AMI, only 12%, 26%, and 32% of eligible patients were of goal doses of beta-blockers, statin, and ACE inhibitors/ARBs, respectively. In adjusted analyses, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up.

Conclusions:

Although most patients are discharged on guideline-based secondary prevention therapy after AMI, most were undertreated at 12 months, with prescribed doses below those with proven efficacy.

Perspective:

The limitations of the analysis aside, this study provides valuable information on the undertreatment of patients following AMI. Performance measures, which currently only capture whether a secondary prevention therapy is prescribed, should potentially capture whether there is active titration of such therapy to goal doses. Attempts to maximize the doses of secondary prevention therapy during the index hospitalization may be a strategy to counter this undertreatment. Future research should provide insight into why medication up-titration occurs infrequently.

Clinical Topics: Dyslipidemia, Prevention, Nonstatins, Novel Agents, Statins

Keywords: Myocardial Infarction, Secondary Prevention, Hydroxymethylglutaryl-CoA Reductase Inhibitors


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