Use Of Secondary Prevention Medications Research Articles

Use of Cardiovascular Disease Secondary Prevention Medications in Four Middle East Countries in a Community Setting.

Evidence-based International clinical practice guidelines, universally recommend secondary prevention medications for those with previous cardiovascular disease (CVD). There is limited data on the community use of these medications in the Middle East (ME). This study assesses the use and predictors of evidence based secondary prevention medications in individuals with a history of CVD [coronary heart disease (CHD) or stroke]. Between 2005 and 2015, we enrolled 11,228 individuals aged between 35-70 years from 52 urban and 35 rural communities from four ME countries, United Arab Emirates (n = 1499), Kingdom of Saudi Arabia (n = 2046), Occupied Palestinian Territory (n = 1668) and Islamic Republic of Iran (n = 6013). With standardized questionnaires, we report estimates of medication use in those with CVD at national level and the independent predictors of their utilization through a multivariable analysis model. Results: Of the total ME cohort, 614 (5.5%) had CVD, of which 115 (1.0%) had stroke, 523 (4.7%) had CHD and 24 (0.2%) had both. The mean age of those with CVD was 56.6 ± 8.8 years and 269 (43.8%) were female. Overall, only 23.5% of those with CVD reported using three or more proven secondary prevention medications, and a substantial proportion (stroke 27.8%, CHD 25.8%) did not take any of these medications. In a fully adjusted analysis, increasing age, female gender, higher education, higher wealth in individual household, residence in a higher income country as well as being obese, hypertensive or diabetic were independent predictors of medication use. The use of secondary prevention medication is low in ME and has not reached the modest recommended WHO target of 50% use of 3 or more medications. Independent factors of higher use were, better socioeconomic status (household wealth, country wealth and education) and better contact and accessibility to health care (increasing age, female gender, obesity, diabetes and hypertension).

Using status of secondary prevention medications in post-stroke dysphagia patients: time to raise awareness and develop special formulations

Post-stroke dysphagia (PSD) is an increasingly common complication of stroke. Despite its intuitively unfavorable impact on secondary prevention medication use, limited awareness is available regarding this issue. Herein, a cross-sectional survey was conducted to determine the current use, patient-perceived needs and preferences for secondary prevention medications among PSD patients. To emphasize the unique context related to dysphagia, we recruited Chinese stroke patients with a duration of less than 5 years. These patients were initially categorized into PSD respondents with and without dysphagia. Among the 3490 eligible respondents, 42.7% reported experiencing dysphagia after stroke. Those PSD respondents were more likely to consume multiple medications and suffer from anticoagulants-associated gastrointestinal bleeding as compared to non-PSD ones (p < 0.001). More crucially, 40.2% of them had frequent difficulty in swallowing pills, 37.1% routinely crushed solid oral dosage forms (SODFs), and 23.5% coughed frequently when taking SODFs. In consequence, 87.4% responded a need for PSD-specific formulations where safe swallowing, easy swallowing, and reduced medication frequency were preferred pharmaceutical factors. These findings demonstrate an unsatisfactory situation and definite needs for PSD patients in using secondary prevention medications. Awareness should be increased to develop PSD-specific formulations for safe and effective secondary prevention.

Use of secondary prevention medications in metropolitan and non-metropolitan areas: an analysis of 41 925 myocardial infarctions in Australia.

People in remote areas may have more difficulty accessing healthcare following myocardial infarction (MI) than people in metropolitan areas. We determined whether remoteness was associated with initial and 12-month use of secondary prevention medications following MI in Victoria, Australia. We included all people alive at least 90 days after discharge following MI between July 2012 and June 2017 in Victoria, Australia (n = 41 925). We investigated dispensing of P2Y12 inhibitors (P2Y12i), statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (ACEIs/ARBs), and beta-blockers within 90 days after discharge. We estimated 12-month medication use using proportion of days covered (PDC). Remoteness was determined using the Accessibility/Remoteness Index of Australia (ARIA). Data were analysed using adjusted parametric regression models stratified by ST elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). There were 10 819 STEMI admissions and 31 106 NSTEMI admissions. Following adjustment across NSTEMI and STEMI, there were no medication classes dispensed in the 90-day post-discharge that differed in a clinically significant way from the least remote (ARIA = 0) to the most remote (ARIA = 4.8) areas. The largest difference for NSTEMI was ACEI/ARB, with 71% (95% confidence interval 70-72%) vs. 80% (76-83%). For STEMI, it was statins with 89% (88-90%) vs. 95% (91-97%). Predicted PDC for STEMI and NSTEMI was not clinically significant across remoteness, with the largest difference in NSTEMI being P2Y12i with 48% (47-50%) vs. 55% (51-59%), and in STEMI, it was ACEI/ARB with 68% (67-69%) vs. 76% (70-80%). Remoteness does not appear to be a clinically significant driver for medication use following MI. Possible differences in cardiovascular outcomes in metropolitan and non-metropolitan areas are not likely to be explained by access to secondary prevention medications.

Impact of a Prior Cancer Diagnosis on Quality of Care and Survival Following Acute Myocardial Infarction: Retrospective Population-Based Cohort Study in England.

An increasing proportion of patients with cancer experience acute myocardial infarction (AMI). We investigated differences in quality of AMI care and survival between patients with and without previous cancer diagnoses. A retrospective cohort study using Virtual Cardio-Oncology Research Initiative data. Patients aged 40+ years hospitalized in England with AMI between January 2010 and March 2018 were assessed, ascertaining previous cancers diagnosed within 15 years. Multivariable regression was used to assess effects of cancer diagnosis, time, stage, and site on international quality indicators and mortality. Of 512 388 patients with AMI (mean age, 69.3 years; 33.5% women), 42 187 (8.2%) had previous cancers. Patients with cancer had significantly lower use of ACE (angiotensin-converting enzyme) inhibitors/angiotensin receptor blockers (mean percentage point decrease [mppd], 2.6% [95% CI, 1.8-3.4]) and lower overall composite care (mppd, 1.2% [95% CI, 0.9-1.6]). Poorer quality indicator attainment was observed in patients with cancer diagnosed in the last year (mppd, 1.4% [95% CI, 1.8-1.0]), with later stage disease (mppd, 2.5% [95% CI, 3.3-1.4]), and with lung cancer (mppd, 2.2% [95% CI, 3.0-1.3]). Twelve-month all-cause survival was 90.5% in noncancer controls and 86.3% in adjusted counterfactual controls. Differences in post-AMI survival were driven by cancer-related deaths. Modeling improving quality indicator attainment to noncancer patient levels showed modest 12-month survival benefits (lung cancer, 0.6%; other cancers, 0.3%). Measures of quality of AMI care are poorer in patients with cancer, with lower use of secondary prevention medications. Findings are primarily driven by differences in age and comorbidities between cancer and noncancer populations and attenuated after adjustment. The largest impact was observed in recent cancer diagnoses (<1 year) and lung cancer. Further investigation will determine whether differences reflect appropriate management according to cancer prognosis or whether opportunities to improve AMI outcomes in patients with cancer exist.

Impact of clinical diagnosis of myocardial infarction in patients with elevated cardiac troponin

ObjectiveType 2 myocardial infarction (MI) and myocardial injury are common conditions associated with an adverse prognosis. Physicians experience uncertainty how to distinguish these conditions, as well as how to manage...

A CROSS SECTIONAL ANALYTICAL STUDY ON ADHERENCE AND PERSISTENCE OF CONTINUING SECONDARY PREVENTIVE MEDICINES FOR STROKE AT THE END OF 3 MONTHS IN A TERTIARY CARE CENTRE IN SOUTH INDIA

Prevalence of stroke in India is 90-222/100000 population. It causes so much morbidity to patient and family. Several classes of drugs are effective in preventing stroke recurrence by modifying the risk factors. There is limited data on long-term use of secondary prevention medications following stroke. Persistence is dened as the continuation of all medications patient was last prescribed at the end of 3 months. Adherence is dened as taking modied medications as per needs as per doctor's advice. A Methodology: ll patients with stroke both is chaemic and haemorrhagic and age more than 18 years , sustained in the one year when study is conducted as from the records of neurology department and attending the department for follow up are taken for study. A semi structured interview is done with them or their care givers to get information on their background characteristics, aetiology of stroke, comorbidities, cost of medication and affordability, various classes of medications administered and whether they are persistent in taking drugs, are they adherent to drugs, if not adherent/persistent ,reason for the same by open ended questions. A total of 260 patients were included, mean age was 58.5 years. Result: 78.5% had 3-month persistence and 3 month adherence 35.6%. Independent predictors of 3 month medication persistence included age more than 60 years, marital status, fewer medications prescribed at discharge and patients taking anti hypertensives . Most common reason for non-persistence was because the patients did not know why medication is being taken by them. Various factors play a role in persistence and adherenc Conclusion: e of medications in stroke. A multifactorial intervention including patient and health care providers are warranted, because of morbidity and mortality associated with every episode of stroke.

Association of secondary prevention medication use after myocardial infarction with mortality in hemodialysis patients.

Mortality after myocardial infarction (MI) among patients undergoing dialysis is high. However, studies investigating the use of secondary prevention medications after MI and clinical outcomes in dialysis patients are lacking. This study aimed to examine the association of the number of guideline-recommended medications (antiplatelets, β-blockers, statins and renin-angiotensin-aldosterone system inhibitors) with all-cause mortality after MI in hemodialysis (HD) patients. We conducted a nationwide cohort study of incident HD patients who were admitted for MI between 1 January 2010 and 31 December 2014 and were followed up until 31 December 2015, using Taiwan's national health insurance research database. Of 1471 patients (mean age 68years, 41.9% women) included in the analysis, 281 (19.1%) were treated with one cardioprotective medication, 406 (27.6%) with two, 490 (33.3%) with three and 294 (20%) with four. During a median follow-up of 1.0years, 458 (31.1%) patients died. In a multivariable Cox model, each additional use of guideline-recommended therapies was associated with a significant 12% reduction in the risk of mortality {hazard ratio [HR] 0.88 [95% confidence interval (CI) 0.80-0.97]}. Similar results were obtained in the analysis with the inverse probability of treatment weighting [HR 0.84 (95% CI 0.77-0.92)] and in the propensity score-matched subcohort [HR 0.87 (95% CI 0.77-0.98)]. The decreased mortality risk was consistently observed across all subgroups. The use of more evidence-based medications for secondary prevention after MI was associated with a lower risk of all-cause mortality in HD patients.

Prevalence of cardioprotective medication use in coronary heart disease patients in South America: systematic review and meta-analysis

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Coronary heart disease (CHD) is the most common cause of death globally, and clinical guidelines recommend cardioprotective medications for patients with established CHD. Suboptimal use of these medications has been reported, but an overview from the South American region is lacking. Purpose Our aim is to summarize evidence on the prevalence of cardioprotective medication use for secondary prevention of CHD in South America. We also intend to explore time-trends, guideline compliance and factors associated with medication use. Methods We conducted a systematic review searching literature in PubMed, Embase, Cochrane, Lilacs and SciElo. We searched articles published from 2000 to 2021 that reported prevalence of secondary prevention medication use in South America. We pooled the prevalence estimates in a meta-analysis, described findings on guideline compliance, and used meta-regression models to analyse time-trends and identify factors associated with medication use. Results We identified 7388 publications, from which 73 were included in the review (Fig 1). Medication prevalence varied by class: beta-blockers 73.0%(95%CI 66.6%–79.1%), ACEI/ARBs 55.8% (95%CI 49.7%–61.8), antiplatelets 84.6% (95%CI 79.6%–88.5%), acetylsalicylic acid 85.1% (95%CI 79.7%–89.3%) and statins 78.5% (95%CI 70.7%–84.7%). Heterogeneity of the pooled estimates was high. Ten publications reported low medication use and nine reported adequate use. The use of beta-blockers, ACEI/ARBs and statins significantly increased from 1993 to 2020. Medication use was lower in community, public and rehabilitation settings compared to tertiary centres. Conclusion The use of most cardioprotective medication classes for secondary prevention of CHD in South America has increased over the last 20 years, but it could be further improved particularly in community settings.

Medication use to manage comorbidities in people with dementia: a systematic review

AbstractAimTo investigate physical health outcomes associated with medications prescribed to manage chronic physical conditions in people living with dementia; and determine whether a dementia diagnosis altered drug utilisation patterns for physical health conditions.Data sourcesMedline, Embase, Central and Scopus were searched 01/2011 to 12/2020.Study selectionExperimental and observational studies, where participants with dementia using medications prescribed by doctors to prevent or treat one or more chronic comorbid physical condition, were compared to no intervention, usual care, or a non‐dementia comparison group. The outcomes of interest were clinically meaningful physical outcomes, and medication utilisation patterns.ResultsTen studies met the inclusion criteria. All were of medium to high quality relative to their study design. Mixed findings were reported for ischemic stroke (n = 3), all‐cause mortality (n = 3) and bleeding‐related outcomes (n = 2). This is likely due to the heterogeneity in exposures reported. One study found that people with dementia, receiving antidiabetic management, had a higher rate of severe hypoglycaemia compared to people without dementia. Medication utilisation pattern outcomes included oral anticoagulant use before stroke‐related hospitalisation (n = 1), antithrombotic medication use before stroke‐related hospitalisation (n = 1), cardiovascular medication use for secondary prevention of ischemic heart disease (n = 1), antidepressant medication discontinuation (n = 1), osteoporosis treatment (n = 1), diabetic medication use (n = 2), and antihypertensive medication discontinuation (n = 1).ConclusionThis systematic review showed there is currently insufficient evidence to conclude that medication management in people with dementia should differ substantially to people without dementia. Comprehensive and high‐quality evidence is needed to improve confidence that medication prescribing achieves optimum clinical outcomes, quality of life, and benefit‐to‐risk determination in this vulnerable population.

Effects on Adherence to a Mobile App-Based Self-management Digital Therapeutics Among Patients With Coronary Heart Disease: Pilot Randomized Controlled Trial.

BackgroundThe adherence to secondary prevention treatment in patients with coronary heart disease (CHD) is low. Digital therapeutics (DTx) refers to an emerging branch of medicine that delivers medical interventions directly to patients using evidence-based, clinically evaluated, technology-based software algorithms or apps to facilitate disease management, which may be an efficient tool to optimize adherence.ObjectiveThis paper aims to investigate the effect of mobile app–based self-management DTx on long-term use of secondary prevention medications in patients with CHD in China.MethodsThis pilot study was a parallel-designed, open-labeled, single-center, randomized controlled trial. Hospitalized patients with CHD admitted to Peking University First Hospital between April 2016 and June 2017 were randomized before discharge on a 1:1 ratio. The intervention group received regular follow-up combined with DTx, which is a self-management mobile app already installed on an Android 5 (Mi Pad 1, Xiaomi Corporation) tablet. Structured data from the hospital informatics system were integrated automatically, and medication, lifestyle intervention plan, follow-up protocol, and patient education materials were also provided according to the diagnosis. Participants could use DTx for self-management at home. The control group was under conventional hospital–based follow-up care. Patients were followed up for 1 year, and the primary end point was the percentage of all guideline-recommended medications at 12 months. The secondary end points included the percentage adhered to standard secondary prevention medications at 6 months, the control rate of lipid profile, and blood pressure at 6 months and 1 year.ResultsAmong 300 randomized patients with CHD, 290 (96.7%) were included in the final analysis, including 49.3% (143/290) and 50.7% (147/290) of patients from the intervention and control groups, respectively. Baseline characteristics were similar between the 2 groups. There was a statistically significant improvement in the percentage of all guideline-recommended medications at 12 months in the intervention group compared with the control group (relative risk [RR] 1.34, 95% CI 1.12-1.61; P=.001), and there was no interaction with baseline characteristics. The intervention group had a significantly higher proportion of patients achieving blood pressure under control (systolic blood pressure <140 mm Hg and diastolic blood pressure <90 mm Hg) and low-density lipoprotein cholesterol <1.8 mmol/L (RR 1.45, 95% CI 1.22-1.72; P<.001 and RR 1.40, 95% CI 1.11-1.75; P=.004, respectively) at 12 months. Furthermore, on logistic regression, the intervention group had a lower risk of withdrawing from guideline-recommended medications (odds ratio 0.46, 95% CI 0.27-0.78; P=.004).ConclusionsAmong patients with CHD, using a mobile app–based self-management DTx in addition to traditional care resulted in a significant improvement in guideline-recommended medication adherence at 12 months. The results of the trial will be applicable to primary care centers, especially in rural areas with less medical resources.Trial RegistrationClinicalTrials.gov NCT03565978; https://clinicaltrials.gov/ct2/show/NCT03565978

Passive Prescription of Secondary Prevention Medical Therapy during Index Hospitalization for Acute Myocardial Infarction Is Prevalent and Associated with Adverse Clinical Outcomes

Secondary prevention therapy reduces death and reinfarction after acute myocardial infarction (AMI), but it is underutilized in clinical practice. Mechanisms for this therapeutic gap are not well established. In this study, we have explored and evaluated the impact of passive continuation compared to active initiation of secondary prevention therapy for AMI during the index hospitalization. For this purpose, we have analyzed 1083 consecutive patients with AMI to a tertiary referral hospital in Hong Kong and assessed discharge prescription rates of secondary prevention therapies (aspirin, beta-blockers, statins, and ACEI/ARBs). Multivariate analysis was used to identify independent predictors of discharge medication, and Kaplan–Meier survival curve was used to evaluate 12-month survival. Overall, prescription rates of aspirin, beta-blocker, statin, and ACEI/ARBs on discharge were 94.8%, 64.5%, 83.5%, and 61.4%, respectively. Multivariate analysis showed that prior use of each therapy was an independent predictor of prescription of the same therapy on discharge: aspirin (odds ratio (OR) = 4.8, 95% CI = 1.9–12.3, P < 0.01), beta-blocker (OR = 2.5, 95% CI = 1.8–3.4, P < 0.01); statin (OR = 8.3, 95% CI = 0.4–15.7, P < 0.01), and ACEI/ARBs (OR = 2.9, 95% CI = 2.0–4.3, P < 0.01). Passive continuation of prior medication was associated with higher 1-year mortality rates than active initiation in treatment-naïve patients (aspirin (13.7% vs. 5.7%), beta-blockers (12.9% vs. 5.6%), and statins (11.0% vs. 4.6%); all P < 0.01). Overall, the use of secondary prevention medication for AMI was suboptimal. Our findings suggested that the practice of passive continuation of prior medication was prevalent and associated with adverse clinical outcomes compared to active initiation of secondary preventive therapies for acute myocardial infarction during the index hospitalization.

Characteristics, treatment patterns, and residual cardiovascular risk of patients with a first acute myocardial infarction: A nationwide population-based cohort study in Norway.

There are few nationwide descriptive studies of longitudinal drug use and residual cardiovascular risk in patients with myocardial infarction (MI) in contemporary clinical practice. The objectives of this work were to describe characteristics and longitudinal cardiovascular drug use of patients with a first acute MI in Norway, and to quantify residual risks of cardiovascular events and death. Using nationwide health registries in Norway, we identified 43 750 adults with a first MI (2010 to 2015) and ≥1 prescription for antiplatelet medication. We described cardiovascular medication post-MI and calculated residual cardiovascular risks. Between 3 months and 13-15 months post MI, medication use dropped from 93.3% to 75.1% for low-dose aspirin, 78.1% to 11.0% for dual antiplatelet therapy, 91.6% to 78.7% for antihypertensives, and 88.0% to 70.7% for lipid-lowering therapy. Incidence rate ratios (IRRs) for recurrent MI were similar between subpopulations at 12 months and notably different at 12-36 months. IRRs (95% CIs) at 12-36 months were 1.52 (1.26-1.82) for 65-74 years, 2.26 (1.88-2.71) for 75-84 years, and 3.97 (3.29-4.79) for ≥85 years (vs. 18-49 years), 2.42 (2.18-2.69) for those with ischaemic heart disease (IHD), 2.26 (1.97-2.59) for peripheral artery disease (PAD), 2.17 (1.98-2.36) for hypertension, and 1.82 (1.65-2.01) for diabetes. In conclusion, secondary prevention medication use 13-15 months following a first MI is suboptimal among patients in Norway. The elderly and those with IHD, PAD, diabetes, or hypertension are at high-risk for recurrent MI/stroke/death and should be managed closely beyond the first year.

Between-hospital variation in outcomes of coronary artery bypass grafting in China, 2013–2019

Abstract Background Coronary artery bypass grafting (CABG) is widely performed across China. Understanding current between-hospital variation is important for further quality improving initiatives. Purpose To assess the between-hospital variation comprehensively on outcomes of isolated CABG, and explore hospital-level characteristics and practice patterns explaining the variation. Methods We used the data of Chinese Cardiac Surgery Registry (2013–2019) to examine the between-hospital variation of outcomes, including in-hospital mortality (or treatment withdrawal) and major complications (mortality, postoperative myocardial infarction, stroke, renal failure, mediastinal infection, and reoperation for bleeding). Multilevel mixed-effect models and propensity score adjusting technique were used to quantify the variability and study hospital-level factors associated with the variation. Risk-standardized mortality rate (RSMR) was used to classify hospital performance. Results Among 60876 patients (62.6 years old, 75.4% male) undergoing isolated CABG in 70 hospitals, the mortality was 2.0% and 5.3% had major complications. After adjusting for patient case-mix, the median hospital RSMR was 2.1% (inter-quartile range [IQR], 1.3%-3.1%), with the median odds ratio (MOR) of 2.1; and 5.7% (IQR, 3.7%-7.5%) for risk-standardized major complications, with the MOR of 1.9. Compared with patients admitted in average-performance hospitals, patients undergoing CABG in worse-performance hospitals had a nearly twofold higher odds of in-hospital mortality (adjusted odds ratio [AOR]=1.92; 95% confidence interval (CI), 1.37–2.69), whereas patients in better-performance hospital had an approximately 60% lower odds (AOR=0.41; 95% CI, 0.30–0.57). Hospital location and average surgeon volume explained 20.2% of the between-hospital variation, where hospital-level perioperative blood transfusion rate and use of secondary prevention medication further contributed to the proportion change variance of 3.3% and 2.3%, respectively. Similar results were obtained for major complications. Conclusion(s) Consistent between-hospital variation of CABG performance exists in China. Improving the clinical practice management and reducing variability may better the overall outcomes. Funding Acknowledgement Type of funding sources: None.

Prevalence of diabetes and impact on cardiovascular events and mortality in patients with chronic coronary syndromes, across multiple geographical regions and ethnicities.

In contrast with the setting of acute myocardial infarction, there are limited data regarding the impact of diabetes mellitus on clinical outcomes in contemporary cohorts of patients with chronic coronary syndromes. We aimed to investigate the prevalence and prognostic impact of diabetes according to geographical regions and ethnicity. CLARIFY is an observational registry of patients with chronic coronary syndromes, enrolled across 45 countries in Europe, Asia, America, Middle East, Australia, and Africa in 2009-2010, and followed up yearly for 5 years. Chronic coronary syndromes were defined by ≥1 of the following criteria: prior myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischaemia, or prior revascularization procedure.Among 32694 patients, 9502 (29%) had diabetes, with a regional prevalence ranging from below 20% in Northern Europe to ∼60% in the Gulf countries. In a multivariable-adjusted Cox proportional hazards model, diabetes was associated with increased risks for the primary outcome (cardiovascular death, myocardial infarction, or stroke) with an adjusted hazard ratio of 1.28 (95% confidence interval 1.18, 1.39) and for all secondary outcomes (all-cause and cardiovascular mortality, myocardial infarction, stroke, heart failure, and coronary revascularization). Differences on outcomes according to geography and ethnicity were modest. In patients with chronic coronary syndromes, diabetes is independently associated with mortality and cardiovascular events, including heart failure, which is not accounted by demographics, prior medical history, left ventricular ejection fraction, or use of secondary prevention medication. This is observed across multiple geographic regions and ethnicities, despite marked disparities in the prevalence of diabetes. ISRCTN43070564.

Effect of Secondary Prevention Medication on the Prognosis in Patients With Myocardial Infarction With Nonobstructive Coronary Artery Disease.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) has been and remained a puzzling clinical entity. The role of secondary prevention therapy in patients with MINOCA remains unclear. This study aimed to evaluate the associations between secondary prevention medications and outcomes in patients with MINOCA. A total of 259 patients with MINOCA were consecutively enrolled. Basic information and medication of patients were assessed. We defined major adverse cardiovascular events as the primary end point and angina rehospitalization as the secondary end point. Logistic regression models were used to assess the correlation between treatment and outcomes. The proportion of statins, aspirin, clopidogrel, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB), and β-blocker used at admission was 88.8%, 86.9%, 84.6%, 51.7%, and 61.4%, respectively. At discharge, patients with MINOCA were less likely to be released on statins, aspirin, clopidogrel, ACEI/ARB, and β-blocker. The use of secondary prevention medications was significantly lower at 2 years of follow-up with the most significant reductions being clopidogrel 29.4%, ACEI/ARB 39.0%, and aspirin 42.3%. About 19.1% of patients with MINOCA suffered adverse events during the follow-up period. Adverse events risk decreased when statins and ACEI/ARB were used, whereas the risk of adverse events was not lower in patients with aspirin, clopidogrel, and β-blocker. In conclusion, patients with MINOCA were less likely to receive secondary prevention medications at the time of discharge and early discontinuation of medications at the time of follow-up. Statins and ACEI/ARB were the only medications substantially associated with lower adverse events; by comparison, aspirin, clopidogrel, and β-blocker seem to have no impact on prognosis.

Prevalence, Clinical Factors, and Outcomes Associated With Myocardial Infarction With Nonobstructive Coronary Artery.

Myocardial infarction with nonobstructive coronary arteries (MINOCA) is an underrecognized clinical problem in patients presenting with acute coronary syndrome. Various clinical disorders lead to MINOCA thus making treatment and diagnosis a challenge. We aimed to compare the clinical factors and outcomes of patients with MINOCA versus obstructive disease [myocardial infarction due to coronary artery disease (MI-CAD)] in a largely rural health system. Between May 1, 2009 and June 24, 2019, all consecutive ST-segment elevation myocardial infarction patients at Essentia Health were prospectively examined. We categorized patients into MI-CAD (obstructive plaque ≥ 50% with revascularization) or MINOCA (obstructive plaque < 50% with exclusion of other alternative cause). Outcomes included 30-day and 1-year all-cause mortality, 30-day all-cause readmission and 30-day cardiac readmission. There were 2170 patients included in the study; 2097 (96.6 %) had MI-CAD and 73 (3.4%) met the definition of MINOCA. Within the MINOCA group, the 3 most common presentations were supply-demand mismatch (28.8%), spontaneous coronary artery dissection (9.6%), and other etiology (60.3%). Only 10 (13 %) MINOCA patients had cardiac magnetic resonance imaging studies obtained within 6 months. MINOCA patients were younger 61.6 versus 63.4 years with higher left ventricular function 51.6% versus 50.4% with less likelihood of prior myocardial infarction 4.1% versus 15.5% or congestive heart failure 2.7% versus 6.3% (P < 0.05). Compared with MI-CAD patients, MINOCA patients had similar 30-day mortality (7.1% vs. 8.2%; P = 0.70), 1-year mortality (10.4% vs. 8.2 %; P = 0.55), and 30-day cardiac readmission (8.7% vs. 9.6%; P = 0.29). MINOCA patients were less likely to be discharged on aspirin, betablockers, angiotensin-converting enzyme inhibitor/angiotensin receptor blockers, or statins (P < 0.05). Though there was no difference in readmission and mortality between MINOCA and MI-CAD; use of secondary prevention medications and cardiac rehabilitation referral was low in MINOCA patients. Prospective studies will be relevant to assess effective medical therapy to improve outcomes in MINOCA patients.

Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke.

To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA. This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation. Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation. Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.

Positive Influence of Stroke Health Manager on Risk Factors Control and Medication Adherence After Ischemic Stroke.

Background: From 2017, the Stroke Health Manager Training Project was carried out by the Chinese Government to strengthen health management and follow-up intervention after ischemic stroke. The aim of this study was to investigate whether after the intervention of the stroke health manager, the control of blood pressure, low-density lipoprotein cholesterol (LDL-C), glucose level, and the use of secondary prevention medications improved 3 months after discharge from our center following ischemic stroke.Methods: The study used a history-controlled approach. Patients who received stroke health manager intervention from May 1, 2018, to March 31, 2019, were considered as the intervention group; those from May 1, 2017, to April 30, 2018, were enrolled as the control group. Stroke health manager intervention included health education, discharge advice, online WeChat public group follow-up, and clinical consultation.Results: In total, 642 patients with ischemic stroke were enrolled in this study (277 in the control group, 365 in the intervention group). At 3 months, the blood pressure, LDL-C and glucose control in the intervention group were better than in the control group (all P < 0.05). At the same time, the overall persistence for secondary prevention medications at 3 months after discharge increased from 201/277 (72.56%) to 303/365 (83.01%, P = 0.001). The persistence for patients taking antiplatelet, hypoglycemic and statins were significantly higher in the intervention group (P < 0.05).Conclusions: Stroke health manager intervention improved the control of blood pressure, LDL-C, glucose levels and the persistence for secondary prevention medications 3 months after discharge.

Socioeconomic Factors, Secondary Prevention Medication, and Long-Term Survival After Coronary Artery Bypass Grafting: A Population-Based Cohort Study From the SWEDEHEART Registry.

BackgroundLow income and short education have been found to be independently associated with inferior survival after coronary artery bypass grafting (CABG), whereas the use of secondary prevention medications is associated with improved survival. We investigated whether underusage of secondary prevention medications contributes to the inferior long‐term survival in CABG patients with a low income and short education.Methods and ResultsPatients who underwent CABG in Sweden between 2006 to 2015 and survived at least 6 months after discharge (n=28 448) were included in a population‐based cohort study. Individual patient data from 5 national registries, including the SWEDEHEART (Swedish Web System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) registry, covering dispensing of secondary prevention medications (statins, platelet inhibitors, β‐blockers, and RAAS inhibitors), socioeconomic factors, patient characteristics, comorbidity, and long‐term mortaity were merged. All‐cause mortality risk was estimated using multivariable Cox regression models adjusted for patient characteristics, baseline comorbidities, time‐updated secondary prevention medications, and socioeconomic status. Long‐term mortality was higher in patients with a low income and short education. Statins and platelet inhibitors were dispensed less often to patients with a low income, both at baseline and after 8 years. The decline in dispensing over time was steeper for low‐income patients. Short education was not associated with reduced dispensing of any secondary prevention medication. Use of statins (adjusted hazard ratio=0.57 [95% CI, 0.53–0.61]), RAAS inhibitors (adjusted hazard ratio=0.78 [0.73–0.84]), and platelet inhibitors (adjusted hazard ratio=0.74 [0.68–0.80]) were associated with reduced long‐term mortality irrespective of socioeconomic status.ConclusionsSecondary prevention medications are dispensed less often after CABG to patients with low income. Underusage of secondary prevention medications after CABG is associated with increased mortality risk independently of income and extent of education.

Secondary prevention medications after coronary artery bypass grafting and long-term survival: a population-based longitudinal study from the SWEDEHEART registry.

AimsTo evaluate the long-term use of secondary prevention medications [statins, β-blockers, renin–angiotensin–aldosterone system (RAAS) inhibitors, and platelet inhibitors] after coronary artery bypass grafting (CABG) and the association between medication use and mortality.Methods and resultsAll patients who underwent isolated CABG in Sweden from 2006 to 2015 and survived at least 6 months after discharge were included (n = 28 812). Individual patient data from SWEDEHEART and other mandatory nationwide registries were merged. Multivariable Cox regression models using time-updated data on dispensed prescriptions were used to assess associations between medication use and long-term mortality. Statins were dispensed to 93.9% of the patients 6 months after discharge and to 77.3% 8 years later. Corresponding figures for β-blockers were 91.0% and 76.4%, for RAAS inhibitors 72.9% and 65.9%, and for platelet inhibitors 93.0% and 79.8%. All medications were dispensed less often to patients ≥75 years. Treatment with statins [hazard ratio (HR) 0.56, 95% confidence interval (95% CI) 0.52–0.60], RAAS inhibitors (HR 0.78, 95% CI 0.73–0.84), and platelet inhibitors (HR 0.74, 95% CI 0.69–0.81) were individually associated with lower mortality risk after adjustment for age, gender, comorbidities, and use of other secondary preventive drugs (all P < 0.001). There was no association between β-blockers and mortality risk (HR 0.97, 95% CI 0.90–1.06; P = 0.54).ConclusionThe use of secondary prevention medications after CABG was high early after surgery but decreased significantly over time. The results of this observational study, with inherent risk of selection bias, suggest that treatment with statins, RAAS inhibitors, and platelet inhibitors is essential after CABG whereas the routine use of β-blockers may be questioned.