Guideline-recommended secondary prevention drug therapy after acute myocardial infarction: predictors and outcomes of nonadherence.

BACKGROUND: Guideline-recommended pharmacotherapy after myocardial infarction (MI) has been shown to reduce cardiovascular morbidity and mortality. Our objectives were to determine factors of, and to measure outcomes associated with nonadherence after MI. DESIGN: Multicentre, prospective, observational study (Acute Coronary Syndromes Registry). METHODS: We analyzed data of 11,823 consecutive hospital survivors of acute MI and evaluated their discharge medication with the five following drugs: acetyl salicylic acid, clopidogrel, ß-blocker, angiotensin-converting enzyme inhibitor/sartan and statin. Patients receiving less than four drugs (group 1, n=3439, 29.1%) were compared with those receiving 4-5 drugs (group 2, n=8384, 70.9%). The impact of clinical, demographic and treatment factors on not prescribing each of these five drugs at discharge was investigated by using multiple logistic regression models. RESULTS: Patients of group 1 were older, had more comorbidities, more frequently suffered a nonST elevation MI and less often received reperfusion therapy. In the multivariate analysis, group 1 was associated with an increased risk for death at 1-year follow-up [odds ratio (OR): 1.6, 95% confidence interval (CI): 1.4-1.9]. After adjustment for confounding variables chronic oral anticoagulation was the strongest predictor for not receiving acetyl salicylic acid (OR: 19.6, 95% CI: 15.9-24.0) at discharge, no percutaneous coronary intervention within 48 h for not receiving statin (OR: 2.1, 95% CI: 1.9-2.4) and clopidogrel (OR: 10.4, 95% CI: 9.4-11.5), chronic obstructive lung disease for not receiving ß-blocker (OR: 4.2, 95% CI: 3.6-4.9) and chronic renal insufficiency for not receiving angiotensin-converting enzyme inhibitor/sartan (OR: 2.8, 95% CI: 2.2-3.5). CONCLUSION: In clinical practice guideline-adherent secondary prevention drug therapy is linked with an improved 1-year survival. Comorbidities and no interventional treatment were strong negative predictors for guideline-adherent discharge medication.

Efficacy and safety of optimized antithrombotic therapy with aspirin, clopidogrel and enoxaparin in patients with non-ST segment elevation acute coronary syndromes in clinical practice.

In randomized clinical trials enoxaparin in non ST-elevation acute coronary syndromes (NSTE-ACS) has been shown to be more effective than unfractionated heparin in preventing the combined endpoint of death and myocardial infarction. Clopidogrel in combination with aspirin reduced the combined endpoint of death, myocardial infarction and stroke in NSTE-ACS patients compared to aspirin alone. Aim of the present study was to determine the clinical impact of optimized antithrombotic therapy with enoxaparin, clopidogrel and aspirin compared to standard therapy with unfractionated heparin (UFH) and aspirin in NSTE-ACS in clinical practice. We analyzed data of 2,956 consecutive patients with NSTE-ACS and either antithrombotic therapy with enoxaparin, clopidogrel and aspirin or with aspirin and UFH, which were prospectively enrolled in the acute coronary syndromes registry (ACOS) from July 2000 until the end of November 2002. After adjustment for baseline characteristics and PCI the combined endpoint of hospital death and non-fatal reinfarctions was lower in the group with optimized antithrombotic therapy including clopidogrel, enoxaparin and aspirin compared to the control-group with aspirin and UFH (odds ratio 0.30, 95% confidence interval 0.16-0.53). There was no significant difference in major bleedings between the two treatment groups (1.5% vs. 0.9%, P = 0.35), while overall there were more bleeding complications in the group with optimized antithrombotic therapy (4.9% vs. 2.0%, P = 0.005). In clinical practice optimized antithrombotic therapy with aspirin, clopidogrel and enoxaparin in NSTE-ACS is associated with a reduction in the combined endpoint of death and non-fatal reinfarctions compared to standard therapy with aspirin and UFH without increase in major bleeding complications.

Prognostic impact of acute beta-blocker therapy on top of aspirin and angiotensin-converting enzyme inhibitor therapy in consecutive patients with ST-elevation acute myocardial infarction.

The prognostic effect of beta-blocker treatment on ST-elevation acute myocardial infarction (STEMI) is controversially discussed in the era of reperfusion therapy. From the German multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS (MITRA PLUS), 17,809 consecutive patients with STEMI treated with a guideline-recommended therapy with aspirin and an angiotensin-converting enzyme inhibitor were investigated; the prognostic effect of additional acute beta-blocker treatment was analyzed. Patients with cardiogenic shock were excluded. Of included patients, 77.6% received additional acute beta-blocker treatment and 22.4% did not. Patients with beta-blocker treatment were younger and more often received reperfusion therapy. Acute beta-blocker treatment was associated with a lower hospital mortality (univariate analysis 4.9% vs 10.8%, p <0.001; multivariate analysis odds ratio [OR] 0.70, 95% confidence interval [CI] 0.61 to 0.81). Acute beta blockade was significantly associated with a lower hospital mortality in patients without (OR 0.66, 95% CI 0.56 to 0.79) and with (OR 0.76, 95% CI 0.60 to 0.98) reperfusion therapy. The greatest benefit of acute beta-blocker treatment, measured by the number needed to treat to save 1 life, was found in patients with anterior MI, a heart rate > or =80 beats/min, no reperfusion therapy, female gender, and age > or =65 years. In conclusion, acute beta-blocker therapy in the clinical practice of treating patients with STEMI, in addition to aspirin and angiotensin-converting enzyme inhibitor therapy, was independently associated with a significant decrease in hospital mortality in patients with and without reperfusion therapy. High-risk patients with STEMI, such as elderly patients and patients without reperfusion therapy, showed a greater benefit of acute beta-blocker therapy than low-risk patients with STEMI.

Gender differences in acute non-ST-segment elevation myocardial infarction.

To assess gender-based differences in presentation and outcome after non-ST-elevation myocardial infarction (NSTEMI) in clinical practice, this study examined data from the Acute Coronary Syndrome registry, which enrolled 16,817 patients from 2000 through the end of 2002, 6,358 of them with NSTEMIs (34.1% women). Women with NSTEMIs were 7.5 years older, had a history of myocardial infarction and percutaneous coronary intervention or coronary artery bypass graft less often, and were less likely to have smoked. They more often had a history of systemic hypertension and diabetes mellitus, but this difference was due to their older age. Reperfusion therapy was performed less often in women, which still was significant after adjustment for baseline variables (odds ratio 0.71, 95% confidence interval 0.63 to 0.80). Clopidogrel was given less often in women (43.4% vs 56%). After adjustment for age, gender differences in medical therapy with statins, aspirin, and beta blockers were not significant. Hospital mortality was 1.7 times greater in women. This difference was not significant after adjustment for age (odds ratio 1.07, 95% confidence interval 0.84 to 1.35). Women had greater crude long-term mortality, but after age adjustment, this difference was no longer significant (odds ratio 0.92, 95% confidence interval 0.76 to 1.11). In conclusion, women with NSTEMIs were older than men and thus more often had concomitant diseases but less often had a history of myocardial infarction or coronary artery bypass grafts. They less often received acute percutaneous coronary intervention and less often were treated with clopidogrel. However, there was no difference in age-adjusted mortality in women.

The development of door-to-angiography time in the last 14 years for patients with acute ST-elevation myocardial infarction treated with primary coronary intervention: Determinants and outcome. Results from the MITRAplus and OPTAMI registry.

AIM OF THE STUDY: To examine the development of door-to-angiography time (DTA) and to evaluate the impact of door-to-angiography time in patients with ST-elevation myocardial infarction (STEMI) on hospital and one-year mortality. METHODS AND RESULTS: From 1994 to 2008, 5078 patients (pts) and known DTA with acute ST-elevation myocardial infarction were enrolled into the MITRAplus and OPTAMI registry in Germany. Our data showed a reduction of the door-to- angiography time from 80 min to 64 min in the last 14 years (P < 0.001). Over 80% of patients received an angiography less than two hours after admission. The main predictor of a shorter door-to-balloon time was a hypotension with a blood pressure lower than 100 mmHg (OR 1.46, 95%CI: 1.08-1.91). Whereas a history of prior myocardial infarction (OR 0.61, 95%CI: 0.45-0.84), a previous coronary bypass grafting (OR 0.55, 95%CI: 0.33-0.91), age older than 75 years (OR 0.78, 95%CI: 0.62-0.99) and a pre-hospital delay more than three hours (OR 0.78, 95%CI: 0.66-0.93) were independent predictors for a longer of the door-to-balloon time. In the multivariate regression analysis no influence was detected of door-to-angiography time on hospital or one-year mortality. CONCLUSION: The DTA decreased in the last 14 years and is actually very short in Germany. We indentified predictors of a longer door-to-angiography time in clinical practice. Given the overall short in-hospital delay, the observed door-to-angiography time did not have influence on hospital and mid term mortality.

Repeat late instent-stenosis after an interval of four years in the same lesion after bare-metal and drug-eluting stent: a case report.

In 2001, a 71-year old male was admitted to our hospital with unstable angina. The angiography revealed 2-vessel disease with a 90% stenosis of the proximal LAD. A bare-metal stent was implanted. Four years later the angiography showed a 80% instent-stenosis in the bare-metal stent but no progress at the other coronary arteries. A DES was implanted. Again, four years later, the patient presented with non-ST-elevation myocardial infarction. Angiography showed a 90% instent-restenosis, again without any progession of coronary artery disease in the other vessels. Again a DES implanted. Therefore the processes involved in the late instent-stenosis were not influenced by the antiproliferative agent sirolimus.

Chronic total coronary occlusions in patients with stable angina pectoris: impact on therapy and outcome in present day clinical practice.

BACKGROUND: Chronic total coronary occlusions (CTOs) represent a subgroup of coronary lesions with a low procedural success and high recurrence rate. However, there is evidence for a prognostic benefit of revascularizing a CTO. OBJECTIVE: This study assessed the prevalence of CTOs among patients with stable angina pectoris and its impact on therapeutic strategies. METHODS: Between 2001 and 2003, a survey was conducted in 64 sites to analyze the outcome of the first diagnostic angiography in patients presenting with stable angina pectoris (STAR registry). The clinical characteristics, initial angiographic findings, therapeutic strategy and outcome within the first year were analyzed. RESULTS: A total of 2,002 patients were entered into the registry. One-third had at least one CTO. At 1 year, the mortality in patients with a CTO was significantly higher than in those without a CTO (5.5 vs. 3.1%; P = 0.009). This excess mortality was related to a higher prevalence of confounding factors in patients with a CTO such as diabetes and more severe LV dysfunction. Patients with a CTO were more likely to undergo surgery or being treated medically, whereas patients without a CTO were more likely to undergo PCI. If a CTO was treated by PCI the periprocedural and long-term outcome was similar to those with PCI for a non-occlusive lesion. However, periprocedural MACE was higher for patients treated for a non-occlusive lesion without first treating the CTO. CONCLUSIONS: The prevalence of CTOs in patients with stable angina pectoris is high, and it influences the clinical outcome within the first year. The therapeutic strategy is influenced towards a rather conservative approach and lower rates of interventional therapy.

Impact of chronic antithrombotic therapy on hospital course of patients with acute myocardial infarction.

BACKGROUND: Little is known about the influence of chronic antithrombotic therapy on treatment and clinical outcome in patients with acute ST-elevation myocardial infarction (STEMI). HYPOTHESIS: The purpose of this study was to investigate the hospital course of STEMI patients on antithrombotics. METHODS: We analyzed data of consecutive patients with STEMI, who were prospectively enrolled in the German Acute Coronary Syndromes registry between July 2000 and November 2002. Overall, 8224 patients were stratified into 3 groups: group 1 had no prior chronic antithrombotic medication (n = 6004), group 2 was on chronic acetylsalicylic acid (ASA) therapy (n = 2022), and group 3 was on chronic oral anticoagulation therapy (n = 198). RESULTS: Patients on antithrombotic medication were older and had a higher baseline risk profile. The rate of patients receiving early reperfusion (group 1: 74.6%, group 2: 61.2%, group 3: 52.0%) and guideline-adherent adjustment therapy was lower among patients on antithrombotics. Age and left bundle branch block were strong negative predictors for early reperfusion therapy in patients with prior antithrombotic treatment. Infarct size measured by peak creatine kinase level was lower in patients on antithrombotics. Hospital mortality (group 1: 8.0%, group 2: 12.8%, group 3: 16.2%) and major bleeding complications (group 1: 1.6%, group 2 2.0%, group 3 4.1%) were highest in patients on oral anticoagulants. However, after adjustment for confounding factors, prior ASA (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.80-1.21) and oral anticoagulant treatment (OR: 1.06, 95% CI: 0.66-1.71) were not independent predictors for in-hospital death. CONCLUSIONS: Despite a higher risk profile, patients with STEMI on a chronic antithrombotic therapy were less likely to receive early reperfusion therapy. However, after adjustment, prior ASA or oral anticoagulant therapy was not associated with higher in-hospital mortality.

Impact of the body mass index on occurrence and outcome of acute ST-elevation myocardial infarction.

Obesity is a traditional risk factor for the development of cardiovascular disease. However, recent studies have described a better outcome of obese patients in the clinical course of acute coronary syndromes.We investigated the impact of the body mass index (BMI) on occurrence and outcome of acute ST-elevation myocardial infarction (STEMI). Data of 10 534 consecutive patients with STEMI of the German MITRA PLUS registry were analyzed, comparing international classes of the BMI (obesity: BMI >or= 30 kg/m(2), overweight: 25-29.9 kg/m(2), normal weight: 18.5-24.9 kg/m(2)).STEMI occurred at a younger age in obese patients. The obese patients with first STEMI were 3 years younger than the normal weight patients with first STEMI (62.5 vs 65.7 years, p <0.0001).After STEMI has occurred, the obese patients had the lowest hospital (6.0%) and long-term mortality (4.8%) of all compared BMI-groups. In a multivariate analysis, obesity compared to normal weight was associated with a trend of a reduced mortality without significance during the hospital course (OR 0.81, 95% CI 0.60-1.08) and with significance during follow-up (OR 0.56, 95% CI 0.40-0.79).In conclusion, our data show that obesity is a risk factor of a manifestation of STEMI at a younger age compared to normal weight patients. After STEMI has occurred, obesity is associated with a trend of a lower mortality during the following clinical course. Therefore, the focus of prevention should be the reduction of obesity and metabolic syndrome in young people, to avoid the early occurrence of STEMI by primary prevention.