Abstract 208: Physician Adherence to the Prescription of Proven Doses of Secondary Prevention Medications After Acute Myocardial Infarction. Insights from TRIUMPH and PREMIER.

Abstract

Background: Performance measures after an acute myocardial infarction (AMI) are designed to improve quality by explicitly quantifying the use of evidence-based treatments. While current performance measures assess whether patients are prescribed certain medications, the doses used to establish their benefit in clinical trials are not part of the measures. It is unknown whether patients are being discharged on doses with proven effectiveness and whether these doses are increased over time in the outpatient setting. Methods: We assessed doses of beta blockers (BB), statins, and ACE/ARBs at discharge and 6-12 months post-AMI among 6699 patients eligible for these meds from 31 hospitals enrolled in 2 US registries (2003-08). Target doses were defined from clinical trials establishing benefit. Doses were categorized as none, low (<50% target), moderate (50-74% target), or goal (≥75% target). Titration was defined as an increase in dose category from discharge to follow-up. Analyses excluded patients with heart rate <50 (BB), SBP <100 (BB, ACE/ARB), GFR <30 (ACE/ARB), EF>35% (ACE/ARB), or any chart-documented contraindication (all assessed at discharge). Hierarchical logistic models explored factors, including discharge dose, associated with achieving goal dose of each med at follow-up. Results: At hospital discharge, most eligible patients (>87%) were prescribed some dose of each medication, although fewer than 1/5 received goal doses of BB and ∼1/3 were prescribed goal doses of statins or ACE/ARBs (Table). Of patients discharged on suboptimal doses, few were titrated up as outpatients (BB 19%, statins 25%, ACE/ARBs 27%). After adjustment for sociodemographic and clinical factors, only a goal dose of med at discharge was associated with being on goal dose at follow-up. Conclusions: Although ∼90% of eligible patients are discharged on appropriate secondary prevention medications after an AMI, most are prescribed doses far below those with proven efficacy in clinical trials. Importantly, doses are infrequently increased in the outpatient setting. Integration of dose intensity into performance measures may help improve the use of optimal medical therapy and outcomes.