Secondary Prevention Of Myocardial Infarction Research Articles

Myocardial infarction in patients with HIV infection: incidence, risk factors, pathogenesis, clinical performance and treatment

HIV infection increases the risk of premature myocardial infarction (MI) and other atherosclerotic cardiovascular diseases, which are the main noncommunicable cause of death in HIV-infected patients. The review presents the analysis of recent literature on the incidence, prevalence and risk factors of MI in HIV-infected people. It established that MI is associated with the combined effects of traditional cardiovascular risk factors, HIV infection and the cardiometabolic effects of antiretroviral therapy. Pathogenetic features of acute coronary syndrome in HIV infection under conditions of systemic immune-mediated inflammation, hypercoagulation and direct exposure to the virus are highlighted. The clinical features and coronary damage in MI are described. Methods of treating MI are compared. We concluded that the volume and quality of care for patients with HIV and MI is insufficient. From the perspective of possible drug interactions with antiretroviral therapy, effectiveness and safety of methods for secondary prevention of MI was analyzed.

Case report of acute pericarditis-associated Atrial Fibrillation and thromboembolism MI with Non-Obstructive Coronary Arteries (MINOCA)

Myocardial Infarction (MI) with non-obstructive coronary artery disease (MINOCA), defined as MI without coronary artery stenosis ≥50% on invasive angiography, makes up around 6-14% of all MI presentations with one-year all-cause mortality of 4.7%. MINOCA encompasses a heterogeneous group of conditions. Although patients with MINOCA are more likely to have associated hypercoagulable states, they have a better prognosis than patients with obstructive coronary artery disease (CAD) MI. However, 1 in 4 patients with MINOCA may experience another cardiac event in subsequent years, with women having a worse outcome than men. Treatment for MINOCA should therefore be tailored towards the precipitating aetiology as well as secondary prevention of MI for longer-term benefits. We present a case of first episode of acute pericarditis associated with new persistent atrial fibrillation (AF) leading to thromboembolic MINOCA, and highlight the management decisions to individualise treatments for the various issues specific to this case.

Compliance to modification of risk factors for recurrent myocardial infarction in the long term of the disease: a randomized study

Purpose: to study the relationship between awareness and commitment to modifying risk factors for recurrent myocardial infarction in a long period of the disease. Material & Methods: to study the awareness of risk factors and adherence to secondary prevention of myocardial infarction (MI), a representative sample was created. Of 912 patients treated for myocardial infarction, 333 patients were randomized, taking into account proportional distribution in the population by age (under 65 and over 65 years) and gender. The average age of patients was 62.5±9.8 years: 70,27% of men and 29,73% of women. Patients' awareness of risk factors, the use of preventive measures and adherence to treatment were assessed on the basis of a questionnaire. Statistical processing of the obtained material was carried out using the statistical program STATISTICA 12.5 (StatSoft.Inc). Results are presented as mean and standard deviation (M±s), number of options (n). To compare the qualitative characteristics (frequency tables), the χ2 test and Fisher's exact test were used. All participants were informed about the aims of the study and gave written consent to participate in the study. Results: low awareness (Aw) and commitment (Cm) to the modification of such risk factors for recurrent infarction in a long period of the disease as: reduced fat intake Aw 16,52%, Cm 19,4%; regular consumption of vegetables and fruits Aw 11,41%, Cm 9,7%; smoking cessation Aw 15,92%, Cm 11,04%; decrease in alcohol consumption Aw 16,52%, Cm 10,70%; increased physical activity Aw 14,41%, Cm 12,37%; weight loss with its excess Aw 3,0%, Cm 2,34%; avoidance of stress Aw 28,53%, Cm 18,06%. Although the vast majority of patients received appropriate recommendations from the doctor. Conclusions: low awareness of the possibility of modifying heart disease risk factors is associated with the failure to implement such non-pharmacological measures in secondary prevention after MI: decrease in fat intake (χ2=65,12; p=0,000) and regular consumption of vegetables and fruits (F p=0,000), unwillingness to quit smoking (F p=0,000) and decrease in alcohol consumption (F p=0,000), unwillingness to increase physical activity (χ2=17,61; p=0,000) and reduce weight in case of its excess (F p=0,015), avoiding stress (χ2=27,42; p=0,000).

QiShenYiQi pill inhibits atherosclerosis by promoting reverse cholesterol transport PPARγ-LXRα/β-ABCA1 pathway

Ethnopharmacological relevanceQiShenYiQi pill (QSYQ), a Chinese compound medicine, originate from BuYangHuanWu decoction in the Qing dynasty, and has been used to treat ischemic cardiovascular diseases for more than two hundred years in China. Multi-central randomized double-blind controlled studies have proved that QSYQ has similar efficacy as enteric coated aspirin in the secondary prevention of myocardial infarction. Aim of studyThe aim of study was to explore the effect of QSYQ on reverse cholesterol transport (RCT) pathway during atherosclerosis. Materials and methodsEight-week-old male apoE−/− mice (on the gene background of C57BL/6J) were fed with a high-fat western diet and treated with low dose and high dose of QSYQ, as well as the positive control agent, liver X receptor-α (LXR-α) agonist GW3965. Eight weeks later, mice were sacrificed and the aorta was collected for atherosclerotic analysis. The aortic root was stained with Oil red O to evaluate the area of atherosclerotic lesion, and stained with immunohistochemistry to analyze the intra-plaque component and RCT protein in atherosclerotic plaque. The thoracic aorta was used to detect differentially expressed genes by comparative transcriptome RNA-seq and the protein expression of RCT pathway by western blotting. ResultsAfter eight weeks of treatment, we found that both of QSYQ and LXR-α agonist reduced atherosclerotic plaque area significantly, and decreased the intra-plaque component, including the lipid, the smooth muscle cell and the macrophage. Compared with the control group, there were 49 differentially expressed genes in low-dose QSYQ group, including 21 up-regulated genes and 28 down-regulated genes. The results of GO and KEGG analysis showed that the differentially expressed genes mainly concentrated in the negative regulation of lipid biosynthesis, positive regulation of lipid metabolism, cell response to lipids, negative regulation of lipid storage, fatty acid degradation, and glycerol ester metabolism. Both of QSYQ and LXR-α agonist reduced the protein expression of CD36 and increased the protein expression of PPARγ-LXRα/β-ABCA1 in atherosclerotic plaque. ConclusionThe anti-atherosclerotic mechanism of QSYQ was involved in inhibiting lipid phagocytosis and promoting reverse cholesterol transport, therefore reducing lipid deposition and inflammatory cells in plaque.

Complexity of Inflammation in the Trajectory of Vascular Disease: Interleukin 6 and Beyond

Takayasu's arteritis, first described by Dr. Mikito Takayasu in 1908, is a systemic vasculitis that mostly affects the aorta and its major branches. Although the etiology of the disease is yet unknown, genetic and environmental factors may both play a role. One hundred years after the discovery of Takayasu's arteritis, inflammation is finally widely recognized as a fundamental condition common to all vascular diseases, and clinical trials have proven the efficacy of molecularly targeted drugs that block each step of the NLRP3 inflammasome/interleukin (IL)-1β/IL-6 cascade in patients with atherosclerotic vascular disease and elevated C-reactive protein (CRP). Recent advances have also been made in the treatment of Takayasu's arteritis. The randomized controlled trials and subsequent open-label and post-marketing surveillance studies in Japan have demonstrated that tocilizumab, an anti-IL-6 receptor antibody, is effective in the treatment of Takayasu's arteritis and prevents relapse during tapering of prednisolone doses. IL-6 is also heavily engaged in the remodeling of large vessels after acute aortic dissection as demonstrated in animal studies. In patients with acute aortic dissection, those with markedly elevated CRP levels in the acute phase are known to have an increased risk of aorta-related events, such as rupture due to aortic diameter enlargement, in the subacute and chronic phases. We discovered that elevated CRP levels following aortic dissection are caused by IL-6, which is produced by neutrophils that infiltrate the adventitia of the dissected aorta. In a mouse model of acute aortic dissection, we showed that IL-6 produced by these neutrophils causes progressive destruction of the arterial wall structure and that blockade of IL-6 signaling can prevent post-dissection vascular remodeling and improve life outcome. Therefore, inhibiting IL-6 signaling is anticipated to be effective in the secondary prevention of myocardial infarction and suppression of vascular modeling after dissection and even as an anti-inflammatory therapy for Takayasu's arteritis; however, this approach does not solve everything. Undoubtedly, the mechanisms of inflammation in vascular disease are diverse and complex, and the cytokines and cell populations involved at each site (coronary artery vs. aorta) and in each phenotype (atherosclerosis vs. aortic aneurysm vs. aortic dissection) need to be understood for each type of inflammation. Osteopontin (OPN) is a recruiter of monocytes and macrophages, induces cellular immune responses as a Th1 cytokine, acts as a fibrosis-promoting factor, and has been shown to be deeply involved in the pathogenesis of vascular diseases. We have shown that senescent T cells, which emerge with obesity and aging, secrete significant amounts of OPN, leading to metabolic abnormalities and chronic inflammation. Neutrophil extracellular traps (NETs) released from activated neutrophils have been shown to contribute to the pathogenesis of acute coronary syndromes (ACS) by interacting with macrophages, platelets, and vascular endothelial cells and thus promoting plaque erosion and immunothrombosis. In addition to standard anticoagulant and antiplatelet therapies, the effectiveness of anti-immunothrombotic therapies targeting NETs as a new preventive and therapeutic approach for ACS will be examined in the future.

Artificial intelligence for secondary prevention of myocardial infarction: A qualitative study of patient and health professional perspectives

BackgroundArtificial intelligence (AI) has potential to improve self-management of several chronic conditions. However, the perspective of patients and healthcare professionals regarding AI-enabled health management programs, which are key to successful implementation, remains poorly understood. PurposeTo explore the opinions of people with a history of myocardial infarction (PHMI) and health professionals on the use of AI for secondary prevention of MI. ProcedureThree rounds of focus groups were conducted via videoconferencing with 38 participants: 22 PHMI and 16 health professionals. FindingsWe identified 21 concepts stemming from participants' views, which we classified into five categories: Trust; Expected Functions; Adoption; Concerns; and Perceived Benefits. Trust covered the credibility of information and safety to believe health advice. Expected Functions covered tailored feedback and personalised advice. Adoption included usability features and overall interest in AI. Concerns originated from previous negative experience with AI. Perceived Benefits included the usefulness of AI to provide advice when regular contact with healthcare services is not feasible. Health professionals were more optimistic than PHMI about the usefulness of AI for improving health behaviour. ConclusionsAltogether, our findings provide key insights from end-users to improve the likelihood of successful implementation and adoption of AI-enabled systems in the context of MI, as an exemplar of broader applications in chronic disease management.

Myocardial Infarction with Nonobstructive Coronary Arteries.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an important subtype of myocardial infarction (MI) that occurs in approximately 6-8% of patients with spontaneous MI who are referred for coronary angiography. MINOCA disproportionately affects women, but men are also affected. Pathogenesis is more variable than in MI with obstructive coronary artery disease (MI-CAD). Dominant mechanisms include atherosclerosis, thrombosis, and coronary artery spasm. Management of MINOCA varies based on the underlying mechanism of infarction. Therefore, systematic approaches to diagnosis are recommended. The combination of invasive coronary angiography, multivessel intracoronary imaging, provocative testing for coronary spasm, and cardiac magnetic resonance imaging provides the greatest diagnostic yield. Current clinical practice guidelines for the secondary prevention of MI are based largely on data from patients with MI-CAD. Thus, optimal medications after MINOCA are uncertain. Clinical trials focused on the treatment of patients with MINOCA are urgently needed to define optimal care.

Cardiac rehabilitation and secondary prevention after acute myocardial infarction: a modern view on the problem

Cardiovascular diseases remain a heavy socioeconomic burden in the modern world, claiming up to four million lives annually, including one million of the Russian population. Most often, cardiovascular mortality is associated with chronic coronary heart disease and its complications. Despite the progress in the treatment of acute coronary syndrome in the acute disease phase, the problem of recurrent coronary events and associated adequate rehabilitation remains unresolved. Modern Russian and European recommendations for cardiovascular rehabilitation present the main directions of secondary prevention of myocardial infarction, which summarize the global and Russian evidence-based medicine data on the problem and are based on the principles of phasing, continuity, succession, and multidisciplinary approach to the patient management. This review focuses on the problems and shortcomings of secondary prevention and cardiac rehabilitation at the patient, doctor, and healthcare system levels. In addition, contemporary approaches to their elimination are described. The necessity and importance of individual training and informing patients and the formation of their sustainable commitment to a healthy lifestyle and therapeutic and preventive measures prescribed by modern guidelines on this issue are emphasized.

Unresolved issues of increasing physical activity after myocardial infarction

The review presents the results of studies on the problems of increasing the efficiency of rational physical activity within the concept of comprehensive secondary prevention of myocardial infarction. The aspects of insufficient adherence of specialists and patients to rehabilitation methods were discussed; possible safe exercise modes after infarction and available monitoring methods were given. We also described the potential characteristics of physical training, taking into account the initial clinical severity and completeness of revascularization after myocardial infarction. In addition, the need for socio-economic, as well as informational support of the state and healthcare system has been updated.

Aspirin to target arterial events in chronic kidney disease (ATTACK): study protocol for a multicentre, prospective, randomised, open-label, blinded endpoint, parallel group trial of low-dose aspirin vs. standard care for the primary prevention of cardiovascular disease in people with chronic kidney disease

BackgroundChronic kidney disease (CKD) is a very common long-term condition and powerful risk factor for cardiovascular disease (CVD).Low-dose aspirin is of proven benefit in the secondary prevention of myocardial infarction (MI) and stroke in people with pre-existing CVD. However, in people without CVD, the rates of MI and stroke are much lower, and the benefits of aspirin in the primary prevention of CVD are largely balanced by an increased risk of bleeding.People with CKD are at greatly increased risk of CVD and so the absolute benefits of aspirin are likely to be greater than in lower-risk groups, even if the relative benefits are the same. Post hoc evidence suggests the relative benefits may be greater in the CKD population but the risk of bleeding may also be higher. A definitive study of aspirin for primary prevention in this high-risk group, recommended by the National Institute for Health and Care Excellence (NICE) in 2014, has never been conducted. The question has global significance given the rising burden of CKD worldwide and the low cost of aspirin.MethodsATTACK is a pragmatic multicentre, prospective, randomised, open-label, blinded endpoint adjudication superiority trial of aspirin 75 mg daily vs. standard care for the primary prevention of CVD in 25,210 people aged 18 years and over with CKD recruited from UK Primary Care.Participants aged 18 years and over with CKD (GFR category G1-G4) will be identified in Primary Care and followed up using routinely collected data and annual questionnaires for an average of 5 years. The primary outcome is the time to first major vascular event (composite of non-fatal MI, non-fatal stroke and cardiovascular death [excluding confirmed intracranial haemorrhage and other fatal cardiovascular haemorrhage]). Deaths from other causes (including fatal bleeding) will be treated as competing events. The study will continue until 1827 major vascular events have occurred. The principal safety outcome is major intracranial and extracranial bleeding; this is hypothesised to be increased in those randomised to take aspirin. The key consideration is then whether and to what extent the benefits of aspirin from the expected reduction in CVD events exceed the risks of major bleeding.DiscussionThis will be the first definitive trial of aspirin for primary CVD prevention in CKD patients. The research will be of great interest to clinicians, guideline groups and policy-makers, in the UK and globally, particularly given the high and rising prevalence of CKD that is driven by population ageing and epidemics of obesity and diabetes. The low cost of aspirin means that a positive result would be of relevance to low- and middle-income countries and the impact in the developed world less diluted by any inequalities in health care access.Trial registrationISRCTN: ISRCTN40920200. EudraCT: 2018-000644-26. ClinicalTrials.gov: NCT03796156

Healthy nutrition in secondary prevention after myocardial infarction. What to focus on?

Rationalization of dietary behavior in patients after myocardial infarction is the subject of numerous discussions. Despite the proven preventive effect of a healthy diet and the benefits of certain foods in cardiovascular diseases, this type of intervention is still underused. The aim of this review was to analyze current approaches to modifying the nutrition of patients within the secondary prevention of myocardial infarction. For this, 903 publications from PubMed/MEDLINE database over the past 5 years were studied. The Mediterranean diet demonstrated the highest efficacy and safety in preventing athero-thrombotic events among existing dietary patterns. However, its wide reproducibility in different regions is associated with a number of limitations. Government programs to modify and support a healthy diet beyond the conventional low-cholesterol diet may be promising in secondary prevention, especially if patients are properly monitored and motivated.

Impact of Coronary Interventions for Secondary Prevention of Myocardial Infarction among Clinical Nurses

Objective: to assess the effectiveness of structured teaching programme on knowledge of staff nurses regarding selected coronary intervention for secondary prevention of myocardial infarction at a selected hospital, Bangalore. Materials and Methods: Quantitative research approach and a pre experimental one group pre-test and post-test research design were used to accomplish the stated objectives. The investigator selected a sample of 50 staff nurses using a convenience sampling technique. The data were collected by using a structured knowledge questionnaire followed by structured teaching programme regarding secondary prevention of MI was administered for about 45 min. Post test was conducted after 7 days using a same structured knowledge questionnaire. Result: Inferential and descriptive statistical analysis was performed by using SPSS-IBM 20. Results were calculated by using p value < 0.05. The results revealed that, in pre test 88% of the nurses had inadequate knowledge where as in post test 100% of the nurses had gained adequate knowledge on secondary prevention of MI which was statistically significant at P<0.005. There was a significant association found in relation to socio demographic variables such as total years of clinical experience. Conclusion: The study result shows that after intervention knowledge on secondary prevention of MI were improved significantly among the clinical nurses.

The Impact of Urate-Lowering Therapy in Post-Myocardial Infarction Patients: Insights From a Population-Based, Propensity Score-Matched Analysis.

The role of urate‐lowering therapy (ULT) for the primary prevention of cardiovascular (CV) events has been widely discussed, but its evidence for the secondary prevention of myocardial infarction (MI) is limited. Therefore, we conduct a population‐based, propensity score‐matched cohort study to investigate the CV outcomes among patients with post‐MI with and without ULT. A total of 19,042 newly diagnosed in‐hospital patients with MI were selected using the Taiwan National Health Insurance Database between January 1, 2005, and December 31, 2016. After 1:1 propensity score matching with covariates, patients with MI with (n = 963) and without (n = 963) ULT were selected for further analysis. The primary outcome was the all‐cause mortality and the secondary outcomes were composite CV outcomes, including hospitalization for recurrent MI, stroke, heart failure, and cardiac arrhythmias. ULT users were associated with lower all‐cause mortality (adjusted hazard ratio (adjHR), 0.67; 95% confidence interval (CI), 0.51–0.87) compared to the ULT nonusers. In addition, ULT users had a significantly lower risk of recurrent MI, which needed revascularization by percutaneous coronary intervention or coronary artery bypass grafting (adjHR, 0.67; 95% CI, 0.53–0.86) than the ULT nonusers. The primary and secondary outcomes were not different between patients with post‐MI who received uricosuric agents and xanthine oxidase inhibitors. The anti‐inflammatory effect of ULT plays an essential role in MI management. From a real‐world setting, this study shows that ULT is associated with the lower risk of all‐cause mortality in patients with post‐MI. In addition, the result shows the possible lower incidence of repeat revascularization procedures in the ULT users.

Adherence to recommendations for secondary prevention medications after myocardial infarction in Estonia: comparison of real-world data from 2004 to 2005 and 2017 to 2018

BackgroundRelatively high rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported, but register-based, objective real-world data is scarce. We aimed to analyse adherence to guideline-recommended medications for secondary prevention of MI in 2017 to 2018 (period II) and compare the results with data from 2004 to 2005 (period I) in Estonia.MethodsStudy populations were formed based on data from the Estonian Health Insurance Fund’s database and on Estonian Myocardial Infarction Register. By linking to the Estonian Medical Prescription Centre database adherence to guideline-recommended medications for MI secondary prevention was assessed for 1 year follow-up period from the first hospitalization due to MI. Data was analysed using the defined daily dosages methodology.ResultsTotal of 6694 and 6060 cases of MI were reported in periods I and II, respectively. At least one prescription during the follow up period was found for beta-blockers in 81.0% and 83.5% (p = 0.001), for angiotensin converting enzyme inhibitor/angiotensin II receptor blocker (ACEi/ARB) in 76.9% and 66.0% (p < 0.001), and for statins in 44.0% and 67.0% (p < 0.001) of patients in period I and II, respectively. P2Y12 inhibitors were used by 76.4% of patients in period II. The logistic regression analysis adjusted to gender and age revealed that some drugs and drug combinations were not allocated similarly in different age and gender groups.ConclusionsIn Estonia, adherence to MI secondary prevention guideline-recommended medications has improved. But as adherence is still not ideal more attention should be drawn to MI secondary prevention through systematic guideline implementation.

The Effects of Glucose Lowering Agents on the Secondary Prevention of Coronary Artery Disease in Patients with Type 2 Diabetes.

BackgroundPatients with diabetes have a higher risk of requiring repeated percutaneous coronary intervention (PCI) than non-diabetic patients. We aimed to evaluate and compare the effects of anti-diabetic drugs on the secondary prevention of myocardial infarction among type 2 diabetes mellitus patients.MethodsWe analyzed the general health check-up dataset and claims data of the Korean National Health Insurance Service of 199,714 participants (age ≥30 years) who underwent PCIs between 2010 and 2013. Those who underwent additional PCI within 1 year of their first PCI (n=3,325) and those who died within 1 year (n=1,312) were excluded. Patients were classified according to their prescription records for glucose-lowering agents. The primary endpoint was the incidence rate of coronary revascularization.ResultsA total of 35,348 patients were included in the study. Metformin significantly decreased the risk of requiring repeat PCI in all patients (adjusted hazard ratio [aHR], 0.77). In obese patients with body mass index (BMI) ≥25 kg/m2, patients treated with thiazolidinedione (TZD) exhibited a decreased risk of requiring repeat revascularization than those who were not treated with TZD (aHR, 0.77; 95% confidence interval, 0.63 to 0.95). Patients treated with metformin showed a decreased risk of requiring revascularization regardless of their BMI. Insulin, meglitinide, and alpha-glucosidase inhibitor were associated with increased risk of repeated PCI.ConclusionThe risk of requiring repeat revascularization was lower in diabetic patients treated with metformin and in obese patients treated with TZD. These results suggest that physicians should choose appropriate glucose-lowering agents for the secondary prevention of coronary artery disease.

Pharmacological secondary prevention of MI

Patients remain at high risk of recurrent ischaemic events following a myocardial infarction (MI), and the goal of secondary prevention therapy is to reduce the risk of cardiovascular events while reducing symptom burden and extending life expectancy. This article provides an overview of the recommended secondary prevention strategies post‐MI, focusing on pharmacological therapy.

The heart of effective CVD risk management

Cardiovascular disease (CVD) remains one of the leading causes of morbidity and mortality in the UK, and this issue of Prescriber has three articles discussing approaches to managing this risk. On page 13, Simon Beggs and Roy Gardner discuss pharmacotherapy for the secondary prevention of myocardial infarction (MI). There are some really clear ‘key points’ provided for readers to take to their clinical practice regarding established therapies. The authors additionally highlight some of the newer innovations in post-MI cardiovascular risk management, that are perhaps less familiar to many working in primary care; for example, when to start a PCSK9 inhibitor for optimising lipid profile when statins aren't enough, and the role of mineralocorticoid blockade. The emerging, and as yet not fully understood, role of two of the newer antiglycaemic drug classes (SGLT2 inhibitors and GLP-1 receptor blockers) in preventing adverse cardiovascular outcomes is also discussed – probably coming to a NICE guideline near you in the near future. Away from the more traditional pharmacotherapies, David Laight reflects on the role of fish oils for CVD prevention (page 21). Is all that dietary advice about eating two portions of fish a week really justified? David discusses the pharmacological properties and evidence base underpinning these agents, and the future role of prescription omega-3 fatty acid derivatives alongside more established therapies. Talking of which, where would we be without mentioning statins? On page 34, Angus Thompson considers why these particular drugs seem to raise so many worries among patients and the wider public. The evidence certainly suggests these anxieties are unjustified, not just due to the benefits but also the lack of harms. A recent study in the BMJ that used a series of so-called ‘n-of-1’ trials – where individuals are switched between statin and placebo treatment in a random and blinded manner – found no evidence that statins caused muscle symptoms.1 For me, it speaks of the need for us to spend appropriate time with patients to check their understanding of proposed medicines, to address misconceptions and concerns, and to ensure patients are able to make appropriately informed decisions about their prescriptions.

Are weak or negative clinical recommendations associated with higher geographical variation in utilisation than strong or positive recommendations? Cross-sectional study of 24 healthcare services

ObjectivesWhen research evidence is lacking, patient and provider preferences, expected to vary geographically, might have a stronger role in clinical decisions. We investigated whether the strength or the direction of...

Adherence to recommendations for secondary prevention medications after myocardial infarction in Estonia

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Estonian Research Council Introduction High rates of adherence to myocardial infarction (MI) secondary prevention medications have been reported by several studies in Europe. However, results derived from unselected populations registry based data is scarce. Purpose Aim of our study was to analyse adherence to guideline recommended medications for secondary prevention of MI of unselected patient population in Estonia in 2017-2018 and compare the results with data from 2004-2005. Methods Population studied in 2004-2005 was based on Estonian Health Insurance Fund"s (EHIF) database and in 2017-2018 on Estonian Myocardial Infarction Registry (EMIR). EMIR is an ongoing registry recording data from all patients in Estonia diagnosed with MI (ICD-10 I21 – I22). Patients hospitalised due to MI and survived &amp;gt; 30 days formed the study population. By linking to EHIF"s prescription database medication adherence for angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARB), statins, beta blockers (BB) and P2Y12 inhibitors clopidogrel and ticagrelor was assessed during one year follow-up period from first hospitalisation during period studied (at least one reimbursed prescription for the drug group during follow-up period). Results 4900 and 5067 index episodes were defined in 2004-2005 and 2017-2018, respectively. Mean age in the study population was 64.7 (+/- 11.5) and 66.5 (+/- 12.1) for men and 72.7 +/- 9.9 and 76.4 +/- 10.9 for women in 2004-2005 and 2017-2018. Rates of medication adherence among patients who survived &amp;gt; 30 days are presented in the Table. Conclusion Adherence to guideline recommended medication for secondary prevention of MI in Estonia has improved considerably over 13 years. Based on our data there is room for advancement, especially among women and the elderly. Rates of medication adherence.2004-20052017-2018p value (comparison between studies)MEN (n = 2365)WOMEN (n = 1660)TOTAL (n = 4025)MEN (n = 2704)WOMEN (n = 1668)TOTAL (n = 4372)BB, No. (%)1907 (80.6)1344 (81.0)3251 (81.0)2265 (84.0)1385 (83.0)3650 (83.5)0.001ACE/ARB, No. (%)1780 (75.3)1317 (79.3)3097 (76.9)1817 (67.2)1070 (64.1)2887 (66.0)&amp;lt; 0.001Statins, No. (%)946 (40.0)826 (50.0)*1772 (44.0)1910 (70.6)1020 (61.2)*2930 (67.0)&amp;lt; 0.001Statin + ACE/ARB + BB, No. (%)999 (42.2)647 (39.0)1646 (40.9)1336 (49.4)686 (41.1)*2022 (46.2)&amp;lt; 0.001None of the above medications, No. (%)130 (5.5)96 (6.0)226 (5.6)214 (7.9)148 (9.0)362 (8.3)&amp;lt; 0.001P2Y12 inhibitorsNANANA2194 (81.1)1147 (69.0)*3341 (76.4)NABB, beta-blockers; ACE/ARB, angiotensin converting enzyme inhibitors/angiotensin II receptor blockers. NA, not available *P &amp;lt; 0.01 for comparison between men and women with Pearson"s χ2 test. Pearson"s χ2 test used for comparison between studies.

Cost-Effectiveness and Cost-Utility Analysis of the Use of Clopidogrel and Pantoprazole in Comparison with Clopidogrel and Omeprazole for the Secondary Prevention of Myocardial Infarction in Iran.

Objective:Gastrointestinal bleeding, a side effect of clopidogrel, is usually prevented by proton-pump inhibitors (PPIs). Due to omeprazole's inhibitory effects on the liver enzyme CYP2C19, its concomitant use with clopidogrel is argued to increase the risk of myocardial infarction (MI) recurrence, as CYP2C19 activates clopidogrel. Pantoprazole as an alternative PPI has shown no inhibitory effect on CYP2C19. This study investigates the cost-effectiveness of concomitant use of clopidogrel and pantoprazole in MI patients compared to the simultaneous use of clopidogrel and omeprazole.Methods:We used the Markov-modeling technique with a hypothetical cohort of 1000 acute MI patients aged 55 years using Microsoft Excel 2013 software. The study was done from the payer perspective, and a lifetime horizon with 1-year cycles was considered in the model. Life-years gained (LYG) and quality-adjusted life-years (QALYs) were used to quantify the health effects of these interventions. Two separate scenarios of public tariffs and private tariffs with various discount rates (0%, 3%, and 7.2% discounts (only for costs)) were evaluated, and an incremental cost-effectiveness ratio (ICER) was used to report the results. One-way and probabilistic sensitivity analyses were used to deal with uncertainty. Data were sourced from published literature and tariff book of the Iranian ministry of health.Findings:The estimated ICERs were 342 USD/QALY and 236 USD/LYG per patient for the base-case scenario.Conclusion:Abiding by the WHO threshold for cost-effectiveness, the concomitant use of pantoprazole and clopidogrel can be considered cost-effective compared to the use of omeprazole and clopidogrel.