There are strong variations among U.S. hospitals in the proportion of patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) who receive angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) and beta-blockers at discharge, according to a study published Aug. 2 in PLOS ONE.

Using data from ACC's Chest Pain – MI Registry , Nathaniel R. Smilowitz, MD, FACC, et al., looked at variability in discharge prescriptions of ACEI/ARB and beta-blockers among MINOCA patients to assess physician attitudes regarding whether clinical guidelines for MI apply to MINOCA patients. The study included MINOCA patients enrolled in the registry between 2007 and 2014. The study was limited to high-volume hospitals with ≥20 MINOCA discharges during the study period. Discharge prescriptions for ACEI/ARB and beta-blockers were analyzed for each hospital. In addition, the researchers looked at clinical data on left ventricular ejection fraction (LVEF), glomerular filtration rate and diabetes status to identify other indications for ACEI/ARB or beta-blockers.

Clinical data were available for 17,849 MINOCA patients, of whom 8,754 (49%) were excluded because they had another indication for ACEI/ARB or beta-blockers, including LVEF <40%, chronic kidney disease or diabetes. Of the remaining MINOCA patients, the final cohort consisted of 5,913 patients who were discharged from 156 high-volume hospitals. At discharge, between 16% and 88.8% of MINOCA patients at high-volume hospitals received a prescription for ACEI/ARB with a median of 45.6% (Interquartile Range [IQR]: 38%-56.5%). At the same hospitals, between 28% and 97.5% of MINOCA patients received beta-blockers with a median of 74.1% (IQR: 64.7%-80%).

According to the researchers, there is "marked variability" between hospitals in ACEI/ARB and beta-blocker prescriptions given to MINOCA patients at discharge, suggesting "clinical equipoise about the routine use of these agents." They conclude that randomized clinical trials "are necessary to establish the benefit of ACEI/ARB and [beta-blockers] to improve outcomes after MINOCA."

Clinical Topics: Cardiovascular Care Team

Keywords: Stroke Volume, Angiotensin Receptor Antagonists, Patient Discharge, Angiotensin-Converting Enzyme Inhibitors, Glomerular Filtration Rate, Coronary Vessels, Hospitals, High-Volume, Ventricular Function, Left, Myocardial Infarction, Adrenergic beta-Antagonists, Registries, National Cardiovascular Data Registries, Renal Insufficiency, Chronic, Diabetes Mellitus, Chest Pain, Prescriptions, Chest Pain MI Registry

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