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Bridging the Knowing-Doing Gap: Improving Use of Guideline-Recommended Secondary Prevention Therapy | Journal Scan
Study Questions:
Among patients with complex coronary artery disease (CAD) in the SYNTAX trial, what is the use of optimal medical therapy (OMT) after revascularization and its association with clinical outcomes?
Methods:
This was a post hoc analysis of the SYNTAX trial, a prospective, multicenter, randomized trial to compare percutaneous coronary intervention (PCI) against coronary artery bypass grafting (CABG) in patients with complex CAD (left main and/or three-vessel disease). Eligible patients were randomized to CABG or PCI with the TAXUS Express paclitaxel-eluting stent. Medication status was checked at the time of randomization; discharge; and 1-month, 6-month, 1-year, 3-year, and 5-year follow-up. OMT was defined as the combination of at least one antiplatelet drug, statin, beta-blocker, and angiotensin-converting enzyme inhibitor/angiotensin-receptor blocker (ACE-I/ARB). The study endpoint was the impact of OMT on mortality at 5-year follow-up.
Results:
Information on medication status was available in 1,774 (98.6%) participants. Only 29.1% of patients were taking OMT before revascularization and 41.3% at the time of discharge after revascularization. Although OMT was initially higher in PCI-treated patients (50.2% in PCI patients and 31.2% in CABG patients), at 5-year follow-up, the use of OMT was similar and low in both groups (PCI 39.6% and CABG 35.7%). Compared to OMT patients, non-OMT patients had different comorbidities including chronic obstructive pulmonary disease (COPD), peripheral vascular disease, or higher SYNTAX score/EuroSCORE. The use of OMT was associated with a significant reduction in 5-year mortality (hazard ratio [HR], 0.64; 95% confidence interval [CI], 0.48-0.85; p = 0.002).
Conclusions:
In a post hoc study of the SYNTAX trial, just over one-third of patients who underwent revascularization for complex CAD were receiving OMT at 5-year follow-up.
Perspective:
This is an interesting study that draws attention to the critical issue of nonadherence and gaps in the use of secondary prevention. Lack of OMT was associated with 5-year mortality. The benefits of OMT were sustained through 5-year follow-up; as the authors posit, ‘It is therefore likely that OMT exerted its beneficial effects by reducing progression of coronary disease and the propensity for new plaque ruptures in noninstrumented or nonbypassed coronary segments.’ Future efforts and interventions should aim to improve use of OMT; consolidated therapy with a polypill is one approach that has been shown to improve adherence.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Interventions and Coronary Artery Disease, Interventions and Vascular Medicine
Keywords: Coronary Artery Bypass, Percutaneous Coronary Intervention, Coronary Artery Disease, Angiotensin-Converting Enzyme Inhibitors, Drug-Eluting Stents, Stents, Peripheral Vascular Diseases, Platelet Aggregation Inhibitors, Pulmonary Disease, Chronic Obstructive, Secondary Prevention, Comorbidity, Prospective Studies, Follow-Up Studies
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