STEMI patients at highest risk are less likely to receive optimal medical therapy

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Nathan Mewton

Data from the regional emergency cardiovascular (RESCUe) network indicate that patients who have had a ST-segment elevation myocardial infarction (STEMI) and who are increased risk of future events are more likely to be under-treated with preventive pharmacological therapy than STEMI patients with fewer risk factors. They also show that, unsurprisingly, optimal medical therapy is associated with increased one-year survival.

Writing in the American Journal of Cardiology, Danka Tomasevic (Intensive Care Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France) and others report that the aim of their study was to evaluate adherence to the 2017 European Society of Cardiology (ESC) guideline for the management of STEMI. Using data from the RESCUe network, they grouped STEMI patients into four categories: strict optimal therapy, which included all patients prescribed dual antiplatelet therapy (DAPT) and lipid-lowering therapies plus therapy relevant to their individual risk factors (ie. beta-blockers if they presented with symptoms of heart failure during the initial hospitalisation); over-treatment, which included all patients who were prescribed DAPT, lipid-lowering therapy, and a medication that they did not have Class I indication for (ie. beta-blockers when they did not have heart failure), optimal therapy, which combined the strict optimal therapy and over- treatment groups; and under-treatment, which included patients who had at least one Class I recommended drug missing at discharge.

Of 5,161 patients, 2,991 (57.4%) received optimal therapy (with 1,087, 21.1%, in the strict optimal therapy group and 1,904, 36.9%, in the over-treatment group) and 2,170 (42.1%) patients in the under treatment group. Tomasevic et al comment: “There were significant differences between patients in the strict optimal therapy and the under-treatment groups. Strict optimal therapy patients were younger with less diabetes, hypertensions, and history of ischaemic heart disease compared with the under treatment group. There were no differences between the strict optimal therapy and the over-treatment group.”

At one year, survival was significantly increased in the optimal therapy group compared with the under treatment group (p<0.001 for the comparison) but there were no differences in survival between the strict optimal therapy and the overtreatment group. The authors report that, in a global multivariable model, “the association between optimal therapy and mortality remained significant, with a hazard ratio of 0.12 (p<0.001).” They add that heart failure and renal insufficiency were also independent predictors of mortality.

Given that they found that one-year survival was still higher in the strict optimal therapy group after adjustment for the higher rate of comorbidities in the under-treatment group, Tomasevic et al state their study suggests “patients with STEMI in high-risk populations should benefit even more from recommended therapies and that specific measures should be taken to insure better adherence to guidelines for this specific subpopulation.”

The authors observe that patients with higher rates of comorbidities are “less well treated” because of the potential side-effects of treatment (such as bleeding or renal dysfunction) but note “at the same time, this absence of treatment translates directly into mortality”. “Our data suggest that patients with the highest risk are less likely to receive appropriate secondary prevention therapy than those at lower risk; the group with the lowest propensity to receive optimal therapy had not only the highest risk features and mortality rate but also the greatest absolute benefit from optimal therapy,” they conclude.

Speaking to Cardiovascular News, study investigator Nathan Mewton (Louis Pradel Hospital, Hospices Civils de Lyon, Lyon, France) said that “there is clear and confounding evidence that efficient reperfusion with strict optimal drug therapy (beta-blocker when appropriate/ACE inhibitor when appropriate/ MRA when appropriate DAPT/statins) significantly improves mortality following STEMI”.

He noted that in addition to their study showing that patients with more severe status and more comorbidities are those who benefit the most from such therapies, there are also no data “clearly showing the opposite in the literature; that is that efficient reperfusion and strict optimal therapy actually increase mortality”.

According to Mewton, physicians “should do all that is in their power to provide patients with timely reperfusion by primary percutaneous coronary intervention (PCI) and strict optimal therapy prescription upon discharge, regardless of age and comorbidity”.

“Large randomised clinical trials in elderly patients (>80 years) with comorbidities (renal failure; heart failure) are needed to promote strict optimal therapy and primary PCI in these patients who are currently undertreated,” he observed.

Non beta-blocker therapies are infrequently used in patients experiencing angina after PCI

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