Use of Evidence-Based Medical Therapy Steadily Improving in Acute MI Patients Postdischarge

Over a recent 10-year period, there has been an improvement in the prescription of evidence-based medical therapy for patients who survive and are discharged from hospital after an MI, a new analysis shows.

From 2001 to 2011, there was a “significant and relatively consistent” increase in the prescription of aspirin, ACE inhibitors/angiotensin receptor blockers (ARBs), beta-blockers, and statins, investigators report. In 2001, just 25.6% of MI patients were prescribed all four medications at discharge compared with 48.7% of patients in 2011 (P < 0.001).

The proportion of patients discharged without a prescription for any medication or who were prescribed just one of four drugs, declined from 17.3% in 2001 to 4.7% in 2011. Prescriptions of a P2Y12 inhibitor for patients who underwent PCI increased over time—up from 85.5% in 2001 to 94.8% in 2011 (P < 0.001).

“The encouraging trends in medication prescribing practices that we observed are due to a multiplicity of factors including greater accumulation of supportive evidence for the use of these medications over time and improved understanding and emphasis by physicians about the importance of these therapies for secondary disease prevention,” write Raghavendra Makam, MD (University of Massachusetts Medical School, Worcester), and colleagues in their paper published online earlier this month in the American Journal of Cardiology.  

In addition, an improved reliance on critical care pathways and other quality improvement tools may have helped in the implementation of clinical practice guidelines leading to the improved trends, according to the researchers.

The study included 5,253 patients in the metropolitan Worcester area discharged from 11 central Massachusetts hospitals over the 10-year period after a confirmed diagnosis of acute MI. Overall, aspirin was prescribed to 87.0% of patients, ACE inhibitors/ARBs to 62.0% of patients, beta-blockers to 85.6% of patients, and statins to 74.3% of patients. In total, 44.0% of discharged patients received all four medications.

Regarding the temporal trends between 2001 and 2011, prescriptions for aspirin use increased from 76.4% to 92.0% and prescriptions for ACE inhibitors/ARBs increased from 50.4% to 61.8%. Similarly, the prescribing of beta-blockers upon hospital discharge increased from 77.0% to 88.8% while statin use increased from 53.8% to 84.8%. There were large increases in the prescription of all four drugs in patients not previously treated with the medications.

Despite the positive shifts, the researchers say, there are still gaps in treatment. For example, after controlling for demographic and clinical factors that might affect physician prescribing practices, patients not prescribed evidence-based medical therapy were more likely to have a do not resuscitate (DNR) order; to be admitted to a community, nonteaching hospital; to have comorbidities, such as chronic obstructive pulmonary disease and renal disease; and to have presented with NSTEMI. In addition, those not receiving medical therapy were more likely to have undergone CABG surgery and to have had a relatively shorter hospital stay. 

“Several prior studies had also noted that the elderly, among other risk groups, continue to be treated less aggressively with evidence-based therapies in the setting of acute MI as compared with younger patients,” write Goldberg and colleagues. “The lack of association of age, gender, and race with combination medical therapy in the current study may suggest that such treatment disparities have improved over time.”

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