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Secondary Prevention Medications After CABG and Long-Term Survival
Study Questions:
What is the value of long-term use of secondary prevention medications (statins, beta-blockers, renin–angiotensin–aldosterone system [RAAS] inhibitors, and platelet inhibitors) after coronary artery bypass grafting (CABG), and the association between medication use and mortality?
Methods:
The study involved all patients (n = 28,812) who underwent CABG in Sweden from 2006 to 2015 and survived ≥6 months after discharge. Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data were used to assess associations between medication use and long-term mortality.
Results:
Approximately 80% of patients were men, mean age was 67.4 (9.2; range 18-74 years), 70% had normal left ventricular ejection fraction, with indication for CABG of stable coronary artery disease 40% and acute coronary syndrome 60%. Comorbidities at baseline included myocardial infarction 55%, diabetes 30%, heart failure 21%, atrial fibrillation 28%, and hyperlipidemia 50%. Statins were dispensed to 94% of the patients at 6 months after discharge and to 77% 8 years later. Corresponding figures for beta-blockers were 91% and 76%, for RAAS inhibitors 73% and 66%, and for platelet inhibitors 93% and 80%. All medications were dispensed less often to patients ages ≥75 years. Statins (hazard ratio [HR], 0.56), RAAS inhibitors (HR, 0.78), and platelet inhibitors (HR, 0.74) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all p < 0.001). There was no association between beta-blockers and mortality risk (HR, 0.97; 95% confidence interval, 0.90–1.06; p = 0.54).
Conclusions:
The use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG, whereas the routine use of beta-blockers may be questioned.
Perspective:
Very large and long-term observational studies in a single country with a universal health care system provides the opportunity to evaluate multiple drug treatment strategies for the population, but not the individual patient. While selected patients may benefit from beta-blockers, there is little to no evidence of benefit for routine use in coronary disease with or without CABG. Nor does this study support routine use of RAAS inhibitors.
Clinical Topics: Acute Coronary Syndromes, Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Dyslipidemia, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Atherosclerotic Disease (CAD/PAD), Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Nonstatins, Novel Agents, Statins, Acute Heart Failure, Interventions and ACS, Interventions and Coronary Artery Disease
Keywords: Acute Coronary Syndrome, Adrenergic beta-Antagonists, Atrial Fibrillation, Cardiac Surgical Procedures, Coronary Artery Bypass, Coronary Artery Disease, Diabetes Mellitus, Heart Failure, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Hyperlipidemias, Myocardial Infarction, Platelet Aggregation Inhibitors, Renin-Angiotensin System, Secondary Prevention, Selection Bias
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