Patients With Schizophrenia Reap Gains From CV Meds After MI

Ensuring use of proven medications for secondary prevention after MI may help mitigate the excess mortality risk seen in patients with schizophrenia, a Danish cohort study suggests.

Compared with people in the general population who received cardioprotective drugs after MI, patients with schizophrenia who went untreated after MI were nearly nine times more likely to die from any cause during follow-up (HR 8.78; 95% CI 4.37-17.64), according to researchers led by Pirathiv Kugathasan, MSc (Aalborg University Hospital, Denmark).

Exposure to any of five classes of preventive medications in the schizophrenia group, however, lessened that excess risk (HR 1.97; 95% CI 1.25-3.10), and when three classes of medication were used, there was no longer any difference in mortality risk between patients with schizophrenia and their counterparts in the general population, the investigators report in a study published online October 24, 2018, ahead of print in JAMA Psychiatry.

The findings, Kugathasan said, could apply not only to patients with schizophrenia but also to patients with other severe mental illnesses like bipolar disorder and major depression.

“When people with these severe conditions are experiencing cardiac events, we should as health professionals be more aware that these patients are vulnerable, they do have a worse prognosis,” he told TCTMD, adding that these individuals need to be followed more closely. “It’s our responsibility to tell them that they have to take these medications to have a better outcome and also make sure that they actually do take their medications.”

In an accompanying editorial, Benjamin Druss, MD (Emory University, Atlanta, GA), says the study suggests that the excess cardiovascular mortality observed in patients with schizophrenia could be related to poor-quality care.

“Given the well-established benefits of these medications in general populations, these results indicate a critical need to implement population-level approaches to improve uptake of those treatments among individuals with schizophrenia,” he writes.

Such efforts should encompass multiple areas, he indicates, including primary prevention, social determinants of poor health, secondary prevention that is delivered in conjunction with mental health treatment, and tertiary prevention aimed at reducing disability and mortality in patients with both psychiatric and medical conditions.

“The poor outcomes described in the current study demonstrate the dire consequences of failing to provide adequate tertiary prevention in patients with schizophrenia after myocardial infarction,” Druss says. “Improving health outcomes will require addressing coordination between mental health clinicians and medical specialists and between inpatient and outpatient service sectors.”

And, he adds, “as with secondary prevention efforts, these interventions will need to be tailored to differing healthcare systems, reimbursement schemes, and workforces.”

Underdiagnosed and Undertreated

Prior studies have shown that patients with schizophrenia are both underdiagnosed and undertreated when it comes to a variety of somatic diseases, Kugathasan said. He pointed out, too, that there is a big gap in life expectancy—15 to 20 years—to the detriment of patients with schizophrenia compared with the general population.

As in the broader population, cardiovascular disease is a major cause of death for patients with schizophrenia. In fact, the psychiatric condition is associated with particularly high rates of cardiovascular morbidity and mortality, possibly related to frequent smoking and substance abuse. The researchers wanted to see whether the benefits of preventive medications prescribed after MI would have a similar impact in this group.

Using Danish national registries, they looked at data on 105,018 patients admitted with a first-time MI between 1995 and 2015; 684 patients (0.7%) had a schizophrenia diagnosis. Consistent with prior research looking at quality of care, patients with schizophrenia were less likely than those from the general population to undergo PCI and to be prescribed any of the five classes of preventive medications examined in the study: antiplatelets, beta-blockers, vitamin K antagonists, ACE inhibitors, and statins.

Through 796,435 person-years of follow-up, the rate of all-cause death was significantly higher in the schizophrenia group (44.9% vs 26.6%; P < 0.001). About two-thirds of deaths in both groups were due to cardiovascular disease.

Exposure to preventive medications partially mitigated that excess risk, such that there was no difference in mortality between treated patients with schizophrenia and untreated patients from the general population.

Moreover, in an analysis of intensity of therapy, there was no difference in mortality between patients with schizophrenia and others in the setting of treatment with any combination of three classes of cardioprotective drugs (HR 1.05; 95% CI 0.43-2.52).

Though these observational data cannot establish causality, the authors conclude, “given the increased cardiovascular risk among patients with schizophrenia, we believe that the current findings support the use of intensive cardioprotective treatments in patients with schizophrenia.

“In addition,” they continue, “these patients should be provided with accurate treatment that is closely monitored during follow-up, and treatment intensity should be increased after cardiac events in patients with schizophrenia in general because a diagnosis of schizophrenia may be associated with an increased cardiac risk, which potentially can be countered by secondary preventive cardiac treatment.”