Use Of Optimal Medical Therapy Research Articles

The Interplay between Dyslipidemia and Neighboring Developments in Coronary Artery Disease Progression: A Personalized Approach.

(1) Background: Estimates suggest that up to 10% of global annual cardiovascular deaths could be related to environmental factors. Not only air pollution components, but also noise exposure and climate changes, are highlighted as nontraditional causes of cardiovascular morbidity. The aim of this study was to identify possible urbanization risk factors for the progression of coronary artery disease in a group of patients with chronic coronary syndrome. (2) Method: There were 77 patients (50 (65%) males and 27 (35%) females) with a median age of 70 (60-74) years who underwent repetitive angiography due to chronic coronary syndrome between 2018 and 2022. The Gensini score was calculated for assessment of coronary artery disease advancement. Environmental factors including neighboring developments were taken into account in this analysis, including housing, commercial, and industrial developments within 300, 500, and 700 m distances (buffer) from the place of habitation. (3) Results: The multivariable analysis results for prediction of Gensini score progression in relation to 700 m buffer urbanization pointed out the significance of hyperlipidemia (OR: 4.24, 95% CI 1.34-13.39, p = 0.014), initial Gensini score (OR: 1.02, 95% CI 1.00-1.05, p = 0.112), and neighborhood housing (OR: 0.03, 95% CI 0.01-0.49, p = 0.025). (4) Conclusions: Hyperlipidemia and housing neighborhood can be regarded as possible factors for coronary disease progression in patients with chronic coronary syndrome with the use of optimal medical therapy.

Changes of hospital-level variation in use of optimal medical treatment for long-term follow-up from a multi-level methodological approach

Abstract Background Contemporary guidelines documented that optimal medical therapy (OMT) should be prescribed to improve clinical outcome in patients with acute myocardial infarction (AMI). However, the changes of hospital-level variations in prescription rates of OMT for long-term follow-up are unknown. Purpose We aimed to investigate (1) impact of hospital-level variation on the use of each medication and OMT and (2) changes of hospital-level variation in prescription rates of individual medical therapy and OMT during the follow-up. Methods We examined hospital medications of 13,516 AMI patients without documented contraindications to antiplatelet agents, β-blockers (BB), angiotensin-converting enzyme inhibitors (ACE) /angiotensin II receptor blockers (ARB), or statins from the Korean Acute Myocardial Infarction Registry (KAMIR) – National Institute of Health (NIH) database. OMT was defined as use of all 4 indicated medications. Hierarchical generalized linear mixed models estimated hospital-level variation in prescription rates of OMT and each medication after adjustment for patient-level factors. Variation was explored with a median rate ratio (MRR), which estimates the relative difference in risk ratios of 2 hypothetically identical patients at 2 different hospitals. Results The prescription rates of OMT and each effective cardiac medications are presented in Figure. There were substantial decreases in the prescription rates for OMT (from 66.7% to 51.6%) and dual antiplatelet agents (from 99.1% to 50.4%) for 2 years follow-up. After adjustment for patient-level covariates, hospital-level MRR for OMT was 1.47 at discharge, indicating an 47% likelihood that 2 random hospitals would differ in treating identical AMI patients. As the prescription rates of OMT and each effective cardiac medications decreased, adjusted hospital-level MRR for OMT (from 1.47 to 1.22), BB therapy (from 1.35 to 1.15), ACE/ARB therapy (from 1.68 to 1.16), and statin therapy (from 1.19 to 1.06) decreased for 2-year follow-up, whereas MRR for dual antiplatelet therapy increased at 1 year (MRR; 1.61) and 2 years (MRR; 1.63) follow-up (Figure). Among patient-level factors, age >70 years, Killip class>2, obesity, hypertension, previous coronary artery disease, renal dysfunction, reduced ejection fraction, percutaneous coronary intervention was independently associated with the use of OMT. Conclusion Hospital-level variations in the use of OMT and each effective cardiac medications were observed at discharge, but weakened overtime, except for use of dual antiplatelet therapy.

Abstract 18313: Sex Disparities in Optimal Medical Therapy for Ischemic Heart Disease

Background: Despite secondary prevention guidelines recommending optimal medical therapy (OMT) forischemic heart disease (IHD), which includes antiplatelets, statins, renal-angiotensin aldosterone inhibitors (RAASi), and β-blockers, significant sex disparities in OMT utilization have been observed. However, theimpact of national efforts on narrowing this gap in contemporary cohorts remains uncertain. Methods: Using data from the National Health and Nutrition Examination Survey cycles 2011-2020, we examined the distribution and trends of OMT medication classes and combinations used in the preceding 30 days (verified through containers in most cases) among adult men and women with self-reported IHD (myocardial infarction or coronary artery disease). Results: Among 1905 adults included (40.6% women, mean age 65.4years), women had significantlylower proportions of OMT use across all medication classes- antiplatelets (68% vs. 77.7%), statins (57.2% vs. 73.9%), RAASi (45.6% vs. 59.0%), and β-blockers (51.2% vs. 61.1%); as well as combinations such as aspirin+statins (47.4% vs. 64.1%) and all four medications (17.5% vs. 32.5%). After adjusting forsociodemographic and clinical factors, the odds of using antiplatelets (OR 0.71 95%CI 0.52-0.94), statins (OR 0.62, 0.40-0.96), and RAASi (OR 0.56, 0.38-0.84) were significantly lower among women than men,whereas β-blocker use was comparable. Moreover, between 2011 to 2020, fewer women consistentlyreported using statins, RAASi, β-blockers, antiplatelets+statins, and all four medications in each survey cycle. Conclusion: This nationally representative study reveals persistent sex disparities in OMT utilization forIHD, with women receiving suboptimal treatment compared to men. These findings emphasize the urgentneed for novel targeted interventions to address and mitigate the sex disparities in OMT utilization foreffective IHD prevention.

Myocardial infarction care in low and high socioeconomic environments: claims data analysis.

To date, claims data have not been used to study outcome differences between low and high socioeconomic status (SES) patients surviving ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) in the Netherlands. To evaluate STEMI and NSTEMI care among patients with low and high SES in the referral area of three Dutch percutaneous coronary intervention (PCI) centres, using claims data as asource. STEMI and NSTEMI patients treated in 2015-2017 were included. Patients' SES scores were collected based on their postal code via an open access government database. In patients with low (SES1) and high (SES4) status, revascularisation strategies and secondary prevention medication were compared. Atotal of 2065 SES1 patients (age 68 ± 13years, 58% NSTEMI) and 1639 SES4 patients (age 68 ± 13years, 63% NSTEMI) were included. PCI use was lower in SES1 compared to SES4 in both STEMI (80% vs 84%, p < 0.012) and NSTEMI (42% vs 48%, p < 0.002) patients. Coronary artery bypass grafting was performed more often in SES1 than in SES4 in both STEMI (7% vs 4%, p = NS) and NSTEMI (11% vs 7%, p < 0.001) patients. Optimal medical therapy use in STEMI patients was higher in SES1 compared to SES4 (52% vs 46%, p = 0.01) but comparable among NSTEMI patients (39% vs 40%, p = NS). One-year mortality was comparable in SES1 and SES4 patients following STEMI (14% vs 16%, p = NS) and NSTEMI (10% vs 11%, p = NS). Combined analysis of claims data and area-specific socioeconomic statistics can provide unique insight into how to improve myocardial infarction care for low and high SES patients.

Evaluation of Incidence and Risk Factors of Sudden Cardiac Death in Patients with Chronic Coronary Syndrome Attending Physical Training.

Regular physical activity is recommended topatients with chronic coronary syndrome (CCS). However, vigorous physical exercise occurs as a risk factor of sudden cardiac death (SCD). The effect of short-term and irregular exercise is controversial. The aim of this research is to assess the role of regular training in the incidence of SCD and to identify risk factors among patientswith CCS participating in a long-term training program. Data of risk factors, therapy, and participation were collected retrospectively for a 10-year period, assessing the length and regularity of participation. The incidence of SCD and related mortality was registered. ANOVA, χ2 test, and multinominal logistic regression and stepwise analysis were performed. The Incidence of chronic kidney disease (CKD) was higher (p < 0.01) and taking beta-blockers (BBs) was lower (p = 0.04) in the SCD group. Irregular training, lack of BBs, smoking, and CKD increased the risk of SCD, while female sex, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers (ACEI/ARBs), and BBs decreased the risk of SCD. Taking ACEI/ARBs and BBs proved to be a protective factor, emphasizing the use of optimal medical therapy. Assessment of cardiac risk factors and control of comorbidities also proved to be important. The occurrence of SCD was connected to irregular physical activity, probably relating to the adverse effects of ad hoc exercising.

Optimal medical therapy improves outcomes in patients with diabetes mellitus and acute myocardial infarction

AimsWe aimed to explored the association between the use of optimal medical therapy (OMT) in patients with myocardial infarction (AMI) and diabetes mellitus (DM) and clinical outcomes. MethodsBleeding complications in a Multicenter registry of patients discharged with diagnosis of Acute Coronary Syndrome (BleeMACS) is an international registry that enrolled participants with acute coronary syndrome followed up for at least 1 year across 15 centers from 2003 to 2014. Baseline characteristics and endpoints were analyzed. ResultsAmong 3095 (23.2%) patients with AMI and DM, 1898 (61.3%) received OMT at hospital discharge. OMT was associated with significantly reduced mortality (4.3% vs. 10.8%, p < 0.001), re-AMI (4.4% vs. 8.1%, p < 0.001), and composite endpoint of death/re-AMI (8.0% vs. 17.6%, p < 0.001). No difference was observed among regions. Propensity score matching confirmed that OMT significantly associated with lower mortality. After adjusting for confounding variables, OMT, drug-eluting stents, and complete revascularization were independent protective factors of 1-year mortality, whereas left ventricular ejection fraction and age were risk factors. ConclusionsGuideline-recommended OMT was prescribed at suboptimal frequencies with geographic variations in this worldwide cohort. OMT can improve long-term clinical outcomes in patients with DM and AMI.Clinical Trial Registration: NCT02466854 June 9, 2015.

Baseline modern medical management in the BEST-CLI trial

ObjectivesThe use of optimal medical therapy (OMT) in patients with chronic limb-threatening ischemia (CLTI) has not been well-studied. The Best Endovascular vs Best Surgical Therapy in Patients with CLTI study (BEST-CLI) is a multicenter, randomized, controlled trial sponsored by the National Institutes of Health comparing revascularization strategies in patients with CLTI. We evaluated the use of guideline-based OMT among patients with CLTI at the time of their enrollment into the trial. MethodsA multidisciplinary committee defined OMT criteria related to blood pressure and diabetic management, lipid-lowering and antiplatelet medication use, and smoking status for patients enrolled in BEST-CLI. Status reports indicating adherence to OMT were provided to participating sites at regular intervals. Baseline demographic characteristics, comorbid medical conditions, and use of OMT at trial entry were evaluated for all randomized patients. A linear regression model was used to identify the relationship of predictors to the use of OMT. ResultsAt the time of randomization (n = 1830 total enrolled), 87% of patients in BEST-CLI had hypertension, 69% had diabetes, 73% had hyperlipidemia, and 35% were currently smoking. Adherence to four OMT components (controlled blood pressure, not currently smoking, use of one lipid-lowering medication, and use of an antiplatelet agent) was modest. Only 25% of patients met all four OMT criteria; 38% met three, 24% met two, 11% met only one, and 2% met none. Age ≥80 years, coronary artery disease, diabetes, and Hispanic ethnicity were positively associated, whereas Black race was negatively associated, with the use of OMT. ConclusionsA significant proportion of patients in BEST-CLI did not meet OMT guideline-based recommendations at time of entry. These data suggest a persistent major gap in the medical management of patients with advanced peripheral atherosclerosis and CLTI. Changes in OMT adherence over the course of the trial and their impact on clinical outcomes and quality of life will be assessed in future analyses.

Evidence-Based Optimal Medical Therapy and Mortality in Patients With Acute Myocardial Infarction After Percutaneous Coronary Intervention.

Background The secondary prevention with pharmacologic therapy is essential for preventing recurrent cardiovascular events in patients experiencing acute myocardial infarction. Guideline-based optimal medical therapy (OMT) for patients with acute myocardial infarction consists of antiplatelet therapy, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, β-blockers, and statins. We aimed to determine the prescription rate of OMT use at discharge and to evaluate the impact of OMT on long-term clinical outcomes in patients with acute myocardial infarction who underwent percutaneous coronary intervention in the drug-eluting stent era using nationwide cohort data. Methods and Results Using the National Health Insurance claims data in South Korea, patients with acute myocardial infarction who had undergone percutaneous coronary intervention with a drug-eluting stent between July 2013 and June 2017 were enrolled. A total of 35 972 patients were classified into the OMT and non-OMT groups according to the post-percutaneous coronary intervention discharge medication. The primary end point was all-cause death, and the 2 groups were compared using a propensity-score matching analysis. Fifty-seven percent of patients were prescribed OMT at discharge. During the follow-up period (median, 2.0 years [interquartile range, 1.1-3.2 years]), OMT was associated with a significant reduction in the all-cause mortality (adjusted hazard ratio [aHR], 0.82 [95% CI, 0.76-0.90]; P<0.001) and composite outcome of death or coronary revascularization (aHR, 0.89 [95% CI, 0.85-0.93]; P<0.001). Conclusions OMT was prescribed at suboptimal rates in South Korea. However, our nationwide cohort study showed that OMT has a benefit for long-term clinical outcomes on all-cause mortality and composite outcome of death or coronary revascularization after percutaneous coronary intervention in the drug-eluting stent era.

Use of optimal medical therapy in patients with diabetes and atherosclerotic cardiovascular disease: Insights from a prospective longitudinal cohort study.

To examine improvement in the use of optimal medical therapy (OMT) for secondary prevention in patients with atherosclerotic cardiovascular disease (ASCVD) and diabetes. Patients with ASCVD (coronary, cerebrovascular, peripheral) and low-density lipoprotein-cholesterol of 70 mg/dl or higher were enrolled from December 2016 to July 2018 from 107 US sites/physicians (47% cardiology, 41% primary care, 12% other) and prospectively followed for 2 years (current analysis restricted to subgroup with diabetes). OMT was defined as high-intensity lipid-lowering (high-intensity statin, any statin + ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitor), antithrombotic (antiplatelet or anticoagulant), angiotensin-converting enzyme-inhibitor/angiotensin II receptor blocker/angiotensin receptor neprilysin inhibitor (ACE-I/ARB/ARNI) (excluding glomerular filtration rate [GFR] < 30 ml/min/1.73m2 ) and sodium-glucose co-transporter-2 inhibitor (SGLT2i)/glucagon-like peptide-1 receptor agonist (GLP-1 RA) (excluding GFR < 30 ml/min/1.73m2 and type 1 diabetes). Among 1590 patients with ASCVD and diabetes (96% type 2 diabetes), 58% were on high-intensity lipid-lowering therapy at the end of follow-up, 87% antithrombotic, 71% ACE-I/ARB/ARNI and 17% SGLT2i/GLP-1 RA. Overall, 11% of patients received comprehensive OMT, which modestly improved over time (vs. 8% at baseline; P=.002). Patients treated by cardiologists (vs. non-cardiologists) were more likely to be on high-intensity lipid lowering, but less likely to be on an SGLT2i/GLP-1 RA, and thus had lower rates of composite OMT (7.8% vs. 13.7%, P < .001). In a hierarchical multivariable model, older age was associated with lower odds of OMT (OR 0.74 per 10 years, 95% CI 0.60-0.90), whereas private insurance (OR 1.93, 95% CI 1.32-2.84) and coronary disease (OR 1.62, 95% CI 1.01-2.61) were associated with higher odds. The median odds ratio was 1.82 (95% CI 1.03-7.32), indicating a moderate variability in OMT use, independent of patient factors. We found suboptimal use of secondary prevention in US patients with ASCVD and diabetes, with minimal improvement over time. Further efforts are needed to improve the use of secondary prevention therapies in these patients with high residual risk.

Utilizing The Electronic Medical Record To Assess Optimal Medical Therapy In Heart Failure Patients

<h3>Intro</h3> As healthcare payment models continue to shift from fee-for-service to pay-for-performance, adequate tools to measure & manage population health will be critical. Heart failure (HF) remains a prevalent & costly chronic condition that has been difficult to manage on a population basis. Guideline-directed optimal medical therapy (OMT) improves HF outcomes, but significant limitations exist in assessing & improving physician/patient compliance with guideline-directed therapy in real world clinical practice. <h3>Hypothesis</h3> Creating an objective scoring system for HF OMT & integrating it into the EMR can benchmark current medical therapy in HF patients & identify gaps in guideline-directed care. <h3>Methods</h3> A small committee within a 100-physician cardiology practice worked to adapt a proposed HF OMT score published in a JACC:HF editorial to meet updated guidelines & specific practice goals. The different guideline-directed HF medications were assigned scores to be combined to a total HF OMT score for a specific patient. The score was integrated into EMR to calculate prospectively for all patient encounters in which there was a history of LVEF less than or equal to 40% or diagnosis of systolic heart failure without LVEF. The treating physician/APP was not alerted to the calculated score in order to truly assess the baseline use of OMT in HF pts. Results: The HF OMT score was calculated for 1,201 pts at the time of a physician/APP encounter over a one-month period. The average score for all visits was 2.8. Evaluation by medication class & dose reveals significant underutilization of MRA and SGLT2i in HF patients in our practice. <h3>Conclusion</h3> Active management & optimization of guideline driven OMT in HF pts across a population will be critical to improving outcomes & succeeding in the evolving pay-for-performance environment. Long term use of a standardized HF OMT score can identify gaps in care for specific medications, by specific physician/APPs, or related to specific patient factors (race/ethnicity, insurance status, gender). Additionally this score can be used to measure the success of future interventions targeting improved compliance with guideline-directed therapy.

Invasive treatment of claudication: Time for better measures and better controls

Peripheral artery disease (PAD) is a common disease in our aging population, and intermittent claudication (IC) is its most frequent symptom. The current evidence-based practice guidelines support the use of optimal medical therapy, including statins and antiplatelet agents, risk factor management (eg, smoking cessation), and exercise, as the primary strategy.1-4 The appropriate use of invasive procedures for the treatment of IC has remained a controversial subject with significant public health and resource implications.

Clinical Experience of Use of Sacubitril/Valsartan in a Patient with Dilated Cardiomyopathy, Chronic Heart Failure with Reduced Ejection Fraction and Ventricular Arrhythmias

Chronic heart failure is the final stage of the cardiovascular continuum, which is an important cause of disability and reduced life expectancy in developed countries. Optimal medical therapy recommended for patients with symptomatic HF and reduced left ventricular ejection fraction includes angiotensin-converting enzyme inhibitors (or angiotensin II receptor antagonists), beta-blockers and mineralocorticoid receptor antagonists. However, the use of optimal medical therapy does not always lead to the elimination of symptoms, improvement of the quality of life and functional capabilities of patients.&#x0D; Sakubitril/valsartan is a novel combination drug that includes the angiotensin II receptor blocker valsartan and the neprilisin inhibitor sacubitril. In a large PARADIGM-HF clinical trial it demonstrated a 20% reduction in cardiovascular mortality and hospitalization due to decompensation of heart failure compared with standard therapy with enalapril. We report a case of successful use of sacubitril/valsartan in a 61-year-old patient with dilated cardiomyopathy, chronic heart failure with reduced ejection fraction and ventricular arrhythmias. After 6 months of therapy, the patient achieved marked positive dynamics of the clinical status, laboratory and instrumental parameters in absence of any adverse reactions and complications.

Trend of perceived quality of life and functional capacity in outpatients with chronic heart failure and in treatment with sacubitril/valsartan: a real-life experience.

Despite the use of optimal medical therapy, heart failure and reduced left ventricular ejection fraction (HFrEF) remains a leading cause of morbidity, mortality and health care costs. The introduction of angiotensin receptor/neprilysin inhibitors (ARNIs) had a revolutionary impact on the treatment of patients with HFrEF. The aim of the study was to monitor over time the perceived quality of life, the physical performance, the trend of BNP and NT-ProBNP and the NYHA functional class in patients with HFrEF during treatment with sacubitril/valsartan. We enrolled 37 patients (63±10 years old, 76% men) who underwent a total of one-year follow-up. All patients underwent clinical evaluation, 6MWT, blood analysis (in particular, NT-pro-BNP and BNP, renal function test); Kansas City Cardiomyopathy Questionnaire (KCCQ) and the NYHA functional class assessment were also performed, at the beginning of the study and after 3, 6 and 12 months of therapy. We observed at each follow-up a significant improvement of KCCQ score, 6MWT, NT-ProBNP, BNP and NYHA class. However, analyzing the ∆% of variation of each single parameter, the improvement was not uniform in time. We also observed that only 37% of patients tolerated the full recommended dose of sacubitril/valsartan (97/103 mg b.i.d.); of the remaining, 40% tolerated the intermediate dose (49/51 mg b.i.d.) and 23% the minimum (24/26 md b.i.d.). Sacubitril/valsartan therapy improves significantly quality of life, physical effort resistance, BNP and NT-ProBNP and NYHA functional class in patients with HFrEF. Although not all the patients tolerated the maximum recommended dose, the beneficial effects were significant even at lower doses.

Impact of insurance status on ICD implantation practice patterns: Insights from the NCDR ICD registry

Whether insurance status influences practice patterns in implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) defibrillators, when indicated, is not known. We analyzed the NCDR ICD Registry to evaluate associations of insurance status with guidelines-based receipt of CRT, as well as device-type, complication rates, and use of optimal medical therapy defined by guidelines. Among 798,028 patients with de novo ICD implants, we included only patients < 65 years (those older have Medicare) and excluded those admitted before 2006 (n=1,835) or with insurance coverage other than Medicare, Medicaid or private insurance (n=25,695) leaving 286,556 for analysis. Inverse probability of treatment weighting was used to control for imbalances between groups. Mean age was 53 years, 29% were female. Patients with private insuranceand Medicare were more likely to receive CRT-D when indicated (79.6%, OR 1.19 95% CI 1.09-1.28, P <.001 and 78.5%, OR 1.11 95% CI 1.01-1.21 P = .03, respectively) compared to the uninsured (76.7%). The uninsured were also more likely than other groups to receive a single-chamber device. Complication rates did not differ. Uninsured patients were, however, more likely to receive optimal medical therapy, particularly in the subgroup receiving the implant for primary prevention. In propensity-weighted analysis, uninsured patients are less likely to receive CRT when indicated but more likely to be receiving optimal medical therapy at discharge. Reasons for differences in device implantation practices based on insurance status require further study.

Abstract 12910: Use of Optimal Medical Therapy in Patients With Cardiovascular Disease Undergoing Cardiac Rehabilitation

Introduction: Optimal Medical Therapy (OMT) in patients with Coronary Artery Disease (CAD) or Heart Failure (HF) is underused despite known benefits. The rate of OMT use among patients enrolled in Cardiac Rehabilitation (CR) is not well known. Purpose: To describe prevalence and characteristics of OMT use in patients with CAD or HF undergoing CR. Methods: CAD patients were defined as those with prior MI, PCI, CABG, or angina. OMT for CAD patients required all currently guideline-recommended medications (aspirin or antiplatelet, statins, beta-blockers (BB); and ACEi/ARB for concurrent HF or DM). The HF group included patients referred to CR for HFrEF or for another indication and had documented left ventricular systolic dysfunction (LVEF&lt;40%, echocardiography). OMT for HF required BB, spironolactone and either ACEi/ARB or Angiotensin Receptor Neprilysin Inhibitor (ARNI) use. Predictors of OMT were identified using with multivariable logistic regression. Results: From January 2015 to December 2019, 612 patients (mean age: 65, 23% female) with CAD were enrolled in CR, with 483 (79%) patients meeting all OMT criteria. CAD patients on OMT were more likely to have hypertension (85%), hyperlipidemia (94%) but less angina (8%). Prior MI, hypertension, hyperlipidemia, and 6-minute walk distance were significantly associated with OMT use.Of 131 HF patients (mean age: 64, 21% female) enrolled in CR, 23 (18%) met all 3 OMT criteria—99 (76%) and 128 (98%) patients met only 2 or 1 of OMT criteria, respectively. Use of spironolactone (least prescribed), ARNI, and ACEi/ARBs all increased over the study period. Study limitations include lack of control for contraindications to medications. Conclusion: Although it has improved over time, OMT use remains low (HF 18%, CAD 79%) among patients enrolled in CR. CR may represent a unique opportunity to enhance OMT use.

Optimal Medical Therapy Prescription in Patients with Acute Coronary Syndrome in the Netherlands: A Multicenter Pilot Registry.

BackgroundUnlike neighboring countries, the Netherlands does not have a national acute coronary syndrome (ACS) registry to evaluate quality of care.ObjectiveWe conducted a pilot registry in two hospitals to assess the prescription of guideline-recommended therapies in Dutch patients with ACS.MethodsWe included all consecutive patients with ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) (n = 1309) admitted to two Dutch percutaneous coronary intervention centers between March 2015 and February 2016. We collected follow-up medication use and reasons for discontinuation at discharge and 1, 6, and 12 months post-discharge. We assessed the use of optimal medical therapy (OMT), defined as the combined prescription of aspirin, P2Y12 inhibitors, statins, β-blockers, and angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers.ResultsOMT prescription was 43.2% at discharge, 60.1% at 1 month, and 28.7% at 12 months. At 1 month, OMT prescription was significantly lower in patients with NSTEMI (51.8 vs. 65.7% for STEMI; p < 0.001). OMT prescription was lower in women (6 months: 55.4 vs. 62.0%, p = 0.036) and in elderly patients.ConclusionIn this pilot study that aimed to extend a national Dutch ACS registry to patients with STEMI and NSTEMI, OMT prescription was comparable to that in other local registries, was lower in women and patients with NSTEMI, and decreased with increasing age.Electronic supplementary materialThe online version of this article (10.1007/s40256-020-00427-9) contains supplementary material, which is available to authorized users.

IMPACT OF EVIDENCE-BASED EMR POINT-OF-CARE ALERTS IN GUIDING MEDICAL THERAPY IN PATIENTS WITH CONGESTIVE HEART FAILURE

Ensuring adherence to evidence-based management of Heart Failure (HF) in a busy clinical practice is a challenge. An electronic medical records (EMR) system was enabled to alert physicians at the point of care prompting initiation of evidence based therapies in patients suffering from congestive heart failure (CHF). We sought to examine the impact of the point-of-care alerts on physician adherence to evidence based optimal medical therapy in these patients. Baseline, demographics, medication reconciliation, and follow-up data were collected for two groups of patients with diagnosis of HF – Group 1 were treated before (BI) and Group 2 after implementation (AI) of the alert module. Rates of Beta-Blocker (BB), Angiotensin Converting Enzyme Inhibitor (ACEi), Angiotensin II Receptor Antagonist (ARB), and Mineralocorticoid Receptor Antagonist (MRA) use were collected for each patient. Rates of medication use and uptitration to maximal tolerated guideline-indicated dose was examined for each Group. Independent sample T-Test was done to assess significance of change in PR and DC rate. All analysis was done by SPSS (v23). Results: Complete clinical data for 445 patients (Mean Age: 72.8±13.3 years, 70% male, mean LVEF: 34.8%±12.7, 65.4% BI) were included in the analysis. BB Prescription and MTDC adherence were increased by 3.2% (78.7% vs. 81.9%, P=0.11) and 51% respectively (24.4% vs. 75.4%, P < 0.05). ACEi/ARB, and MRA use increased after the intervention (Δ=28.1% and Δ=30%, p < 0.05 respectively). Furthermore, double (BB + ACEi/ARB), and triple (BB + ACEi/ARB + MRA) therapy use increased by 13.2% and 23.7% respectively (P < 0.05) (Table 1). Introduction of automated evidence-based EMR point-of-care alerts resulted in an increased rate of optimal medical therapy use and up-titration to the maximal tolerated guideline-indicated medication dose in patients with heart failure.

P3584Optimal medical therapy improves survival in patients with ischaemic cardiomyopathy: an analysis of the STICH trial

Abstract Background Prior studies have demonstrated underuse of optimal medical therapy (OMT) in patients with coronary artery disease (CAD) after revascularization. However, there are limited studies assessing compliance with OMT on long-term survival in patients with CAD and no studies evaluating the impact of OMT in patients with severe CAD and reduced left ventricular (LV) function. The Surgical Treatment for Ischaemic Heart Failure (STICH) Trial was a randomized clinical trial that compared coronary-artery bypass grafting (CABG) with medical therapy versus medical therapy alone in the treatment of ischemic cardiomyopathy. Purpose This study sought to determine compliance with OMT over time and the impact of OMT compliance on survival in patients with or without revascularization. Methods STICH was a multicenter, randomized clinical trial of patients with an LV ejection fraction of 35% or less and CAD amenable to CABG who were randomized to CABG plus medical therapy (N=610) or medical therapy alone (N=602). A medication history was obtained at hospital discharge or 30 days after enrollment, 1 year, 5 years, and 10 years. OMT was defined as the combination of at least 1 antiplatelet drug, a statin, a beta-blocker, and an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker. The primary outcome was all-cause mortality. Comparison of mortality between the OMT and non-OMT groups was performed using multivariate Cox regression modeling with OMT as a time-dependent covariate. Results Of the 1212 patients randomized, at a median follow-up of 9.8 years, all-cause mortality was 58.9% in the CABG group and 66.1% in the medical therapy group. In the CABG arm, 63.6% of patients were on OMT throughout the study period compared to 66.5% of patients in the medical therapy arm (p=0.3). Those on OMT were younger (59.6 vs. 61.4 years, p&lt;0.001); were more often in NYHA class I-II (67.4% vs. 56%, p&lt;0.001); and lower rates of atrial fibrillation (9.4% vs. 18.1%, p&lt;0.001), current smoking (18.6% vs. 24.5%, p=0.015), and depression (4.8% vs. 8.8%, p=0.005). Those on OMT had higher rates of hyperlipidemia (63.8% vs. 54.4%, p=0.001) and prior myocardial infarction (79.4% vs. 73.1%, p=0.01). There was no difference in sex, diabetes, and hypertension between those on OMT and non-OMT. In multivariate survival analysis, OMT was associated with a significant reduction in mortality (adjusted hazard ratio, 0.69; 95% confidence interval, 0.58–0.81; p&lt;0.001). The treatment effect with OMT (31% relative reduction in mortality over 10 years) was numerically greater than the treatment effect of CABG (24% relative reduction in mortality with CABG versus medical therapy alone). Conclusions OMT improves long-term survival in patients with ischaemic cardiomyopathy regardless of revascularization status. Strategies to improve OMT use and adherence in this population is needed to maximize survival.

Impact of Optimal Medical Therapy at Discharge on One-year Direct Medical Costs in Patients with Acute Coronary Syndromes: A Retrospective, Observational Database Analysis in China

PurposeThis study was conducted to examine the use of optimal medical therapy (OMT), consisting of an antiplatelet, a β-blocker, an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), and a statin combined, after hospital discharge and its relationship with direct medical costs in patients with acute coronary syndromes (ACS) in Tianjin, China. MethodsData were obtained from the Tianjin Urban Employee Basic Medical Insurance database (2011–2015). Data from adult patients with ≥1 hospitalization for ACS between January 2012 and December 2014 were included. Medications including antiplatelets, β-blockers, ACEIs/ARBs, and statins at discharge were recorded, with OMT defined as the use of all 4 indicated medications. Propensity-score matching was conducted to form matched OMT and non-OMT cohorts based on baseline differences. All-cause and ACS-related health care resource utilization and direct medical costs during a 12-month follow-up period were assessed and compared between cohorts. Generalized linear modeling was conducted to assess the association between OMT at discharge and direct medical costs. FindingsA total of 22,041 patients were identified (mean age, 64.7 [10.7] years; 45.6% female), of whom 15.1% (3336) received OMT at discharge. The OMT cohort had fewer patients hospitalized for any cause during follow-up compared with the matched non-OMT cohort (38.1% vs 43.2%; P < 0.001), which was further associated with fewer hospitalizations (1.55 vs 1.64; P = 0.019) and shorter annualized length of stay (15.9 vs 17.2 d; P = 0.041). Despite higher costs of outpatient services (9958 vs 10,060 Chinese yuan [CNY] [P = 0.006]; adjusted difference, +456 CNY [P = 0.004]) (year-2014 1 USD = 6.20 CNY), the OMT cohort had significantly lower all-cause total costs (20,771 vs 22,877 CNY [P = 0.174]; adjusted difference, –2089 CNY [P = 0.006]), driven by lower costs of inpatient services (10,813 vs 12,817 CNY [P < 0.001]; adjusted difference, –2184 CNY [P = 0.001]). The difference in ACS-related total costs between the 2 cohorts was not statistically significant (8535 vs 9304 CNY [P = 0.128]; adjusted difference, –558 CNY [P = 0.214]). ImplicationsReceiving OMT at discharge was associated with fewer hospitalizations and lower all-cause direct medical costs in these patients with ACS in China. Strategies are needed to improve OMT prescribing rates at discharge, which would lead to better clinical prognosis and total cost-savings among patients with ACS in China.

Differentiated approach to the use of optimal medical therapy in patients with various clinical forms of stable ischemic heart disease

A total of 137 male patients with stable ischemic heart disease (SIHD), average age 62.3 ± 7.46 years, were divided into 3 groups depending on the initial measurements of blood pressure (BP) and heart rate (HR). Group 1 included patients with elevated blood pressure and/or heart rate (44.5% of patients); Group 2 included patients with normal blood pressure and/or heart rate (38.7%); Group 3 included patients with lowered blood pressure and/or heart rate (16.8%). Patients of Group 1 received beta-adrenergic blockers (BABs) or non-dihydropyridine calcium channel blockers (NDCCBs), in some cases ivabradine-containing BABs (Raenom®, Gedeon Richter) at doses required to achieve target blood pressure and heart rate. The patients of Group 2 received a limited range of drugs above listed due to their blood pressure and heart rate measurements, and the patients of Group 3 did not receive any due to the low levels of such measurements. Effectiveness of the therapy in patients of Group I was the highest. The use of trimetazidine MB (Predizin MB®, Gedeon Richter) has significantly improved the results of treatment in patients of Groups 2 and 3. Trimetazidine MB added to the therapy in patients of Group 1 improved the effectiveness of treatment. Prolongation of trimetazidine MB therapy contributed to improvement of its anti-ischemic effect. Thus, BABs, NDCCBs and ivabradine entered into the foreground, as an optimal medical therapy (OMT) in patients with elevated blood pressure and heart rate measurements. Trimetazidine MB, and ivabradine in some cases prevail in patients with normal and low blood pressure and/or heart rate. It should be stated that patients with various hemodynamic variants of SIHDa require a differentiated approach to the choice of OMT.