Less Not Always More When Medicating Frail, Elderly Acute MI Patients

Ensuring that frail elderly patients with multiple comorbidities receive all guideline-recommended secondary prevention strategies after an acute MI may be an important key to helping them live longer, new research suggests.

The study focused on a population that presents some of the biggest challenges in secondary prevention: patients in their 80s being cared for in a nursing home. One major problem is the lack of guidance on how best to optimize these individuals’ therapies without impacting their quality of life, lead author Andrew R. Zullo, PharmD, PhD (Brown University School of Public Health, Providence, RI), told TCTMD.

“There's also very little evidence on how to safely combine a new medication with the many other medications that people are often already taking,” he added.

In the study, published online April 9, 2019, in Circulation: Cardiovascular Quality and Outcomes, Zullo and colleagues found that compared with patients who received only one secondary therapy, those who received three or four had a relative 26% lower rate of mortality in the 90 days immediately after an acute MI. Before they were even hospitalized, the average number of medications being taken by the cohort was 11, with hypertension and heart failure being among the most common reasons for daily medication.

“Polypharmacy in this population is often thought about only in quantitative terms: ‘the fewer drugs the better’ without consideration of appropriateness of therapy, goals of care, and patient preference,” write Susan K. Bowles, PharmD, MSc, and Melissa K. Andrew, MD, PhD (both Dalhousie University, Halifax, Canada), in an editorial accompanying the study. “Some may elect to take more medications to reduce short-term risk as they perceive benefit to exceed harm. Others may place a higher value on symptom control over longevity and choose fewer or no medications.”

Benefit Seen Regardless of Age or Cognitive Ability

The retrospective analysis included 4,787 patients with a mean age of 84 years who had been living in a nursing home for about 1 year prior to their acute MI. Approximately half of the patients had moderate-to-severe cognitive impairment, and two-thirds required assistance with activities of daily living.

Following the acute MI, Zullo and colleagues found that the population was fairly evenly divided with about one-third each being prescribed one secondary prevention drug, two drugs, and three or four drugs. Older patients were less likely than younger ones to receive more secondary prevention medications. Those who were prescribed three or four secondary prevention drugs after acute MI had better functional status, less severe cognitive impairment, and had been in a nursing home for less time than those prescribed only one or two drugs.

Despite the decrease in mortality for patients receiving three or four medications compared with one (OR 0.74; 95% CI 0.57-0.97), there were no differences in rates of functional or all-cause rehospitalization. Subgroup analyses demonstrated that the outcomes were not affected by multiple variables including older age and unfavorable cognitive or functional status.

Knowing what matters most and selecting more or less treatment based on those personal values is really the takeaway. Andrew R. Zullo

“It goes to show that even though we might expect those people to not do better, it is possible they could still benefit, especially if living longer matters to them,” Zullo noted.

However, stability analyses showed that compared with just one new secondary prevention medication, multiple new drugs were associated with functional decline regardless of whether the patient was prescribed two (OR 1.27; 95% CI 1.07-1.53) or three or four (OR 1.30; 95% CI 1.03-1.63) drugs.

"Knowing what matters most and selecting more or less treatment based on those personal values is really the takeaway," Zullo said. "Frail older adults who want to maximize their quality of life, based on these results, might consider less intense treatment in consultation with their doctor, pharmacist ,and other clinicians. We shouldn't necessarily be adding medications for all older adults. We really need to have a conversation about what matters most and let that guide treatment."

Need for Monitoring in Nursing Homes

Likewise, the editorialists say the findings raise issues about benefits and risks in the context of patient-specific factors.

“Achieving a mortality benefit while potentially increasing frailty secondary to medication-related harms presents a dilemma for clinicians,” they write. Furthermore, Bowles and Andrew say the data emphasize “the need for appropriate monitoring of medications in the nursing home environment, as well as addressing medication-related harms, should they arise.”

To TCTMD, Zullo said those points are important and require further study in this patient population.

“There’s not a lot of evidence on how nursing-home staff could engage with monitoring adverse effects or addressing harms of polypharmacy,” he observed. “Perhaps even more important is giving them the time to do that. Nursing-home staff work hard and are given so much to do, but typically they don't have the staff they need to be able to do something like monitor for side effects. I think a big part of [addressing this] is figuring out how to provide them with enough time, or how to improve staffing so they can monitor for harms and implement interventions to deal with polypharmacy.”