Ten-Year Statin Adherence in Survivors of ST-Segment Elevation Myocardial Infarction.

Background          Adherence to statins is often sub-optimal and declines over time. Direct costs incurred by patients are frequently cited as responsible for inadequate statin adherence. To determine whether survivors of ST-segment elevation myocardial infarction (STEMI), who benefit from low or no cost drug dispensation, have optimal long-term adherence to statins, we aimed to evaluate the ten-year adherence to statin of these patients. Methods          The AMI-QUEBEC Study follows a cohort of STEMI survivors hospitalized at 17 hospitals in Quebec, Canada during the year 2003. We obtained their 10-year data on lipid lowering therapy (LLT) consumption. Optimal adherence was defined as the proportion of days covered of ≥80%. We used multivariate logistic regression to determine factors independently associated with optimal adherence to statins. Results          Complete 10-year data on statin dispensation was available for 524 patients. Optimal adherence remained stable over time at 80% and more during the 10-year follow-up period. During the last five years, 12% of patients did not use any LLT. Older age, living in less socially deprived areas, concomitant use of angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), and admission to hospitals with percutaneous coronary interventions facilities (PCI-hospitals) were associated with improved statin adherence.   Conclusion Future studies are needed to explore the potential factors associated with concomitant use of ACEI/ARB, and admission to PCI-hospitals that may have optimized statin adherence. Socially deprived patients may benefit from more support and encouragement to enhance their long-term statin adherence.

Prevalence and impact of coronary artery disease in patients with pulmonary arterial hypertension.

The occurrence and impact of coronary artery disease (CAD) among patients with pulmonary arterial hypertension (PAH) are unknown. We aimed to determine the prevalence, clinical correlates, and effect of CAD in patients with PAH. We reviewed the medical records of consecutive patients diagnosed with PAH at a university-based referral center for pulmonary vascular disease from January 1990 to May 2010. The patients systematically underwent right heart catheterization and coronary angiography as a part of their evaluation. The patients with PAH with CAD (defined as ≥50% stenosis in ≥1 major epicardial coronary artery) were compared to patients without CAD. Among the 162 patients with PAH, the prevalence of CAD was 28.4%. The presence of CAD was associated with older age (66.6 ± 11.5 vs 49.2 ± 14.0 years, p <0.001), systemic hypertension, and dyslipidemia. The patients with PAH and CAD had a lower mean pulmonary arterial pressure (44.6 ± 11.1 vs 49.2 ± 14.0 mm Hg; p = 0.02) than patients without CAD. During a median follow-up of 36 months, 73 patients died. The presence of CAD was a predictor of all-cause mortality on univariate analysis (hazard ratio 1.97, 95% confidence interval 1.21 to 3.20) but not on multivariate analysis, which identified older age (hazard ratio 1.03, 95% confidence interval 1.01 to 1.05) and right atrial pressure (hazard ratio 1.08, 95% confidence interval 1.03 to 1.14) as the only independent predictors. In conclusion, our study has demonstrated that CAD is common among patients with PAH. CAD prevalence increases with age, dyslipidemia, and hypertension, but we did not detect an independent prognostic effect of CAD on mortality.

Safety and effectiveness of enoxaparin following fibrinolytic therapy: Results of the Acute Myocardial Infarction (AMI)-QUEBEC registry.

BACKGROUND: Previous randomized controlled trials and meta-analyses demonstrated the superior efficacy of enoxaparin (ENOX) over unfractionated heparin (UFH) in patients with ST segment elevation myocardial infarction (STEMI). The external validity of randomized controlled trials may be limited by selective inclusion of patients who are younger and healthier than the 'real-life' population. OBJECTIVE: To evaluate the safety and effectiveness of ENOX compared with UFH in unselected STEMI patients. METHODS: The safety and effectiveness of ENOX and UFH were compared in STEMI patients who received fibrinolytic therapy at 17 Quebec hospitals in 2003. RESULTS: A total of 498 STEMI patients received systemic anticoagulation, with ENOX and UFH administered in 114 and 384 patients, respectively. There were no differences in baseline characteristics between the two patient groups. The rates of in-hospital major adverse cardiac or cerebral events were 11.4% in the ENOX group compared with 14.0% in the UFH group (P=0.51). In-hospital death or nonfatal reinfarction occurred in 7.9% of patients who received ENOX compared with 9.9% of patients who received UFH (P=0.52). Major bleeding occurred in 4.4% of patients who received ENOX versus 6.0% in patients who received UFH (P=0.51). INTERPRETATION: There was no significant difference in the rates of in-hospital adverse events in the ENOX group compared with the UFH group, when used in the real-life context. Larger observational studies may further confirm the safety, effectiveness and optimal duration of the administration of ENOX in unselected STEMI patients treated with fibrinolysis.

HISTORIQUE : Des essais aléatoires et contrôlés et des méta-analyses passés ont démontré l'efficacité supérieure de l'enoxaparine (ENOX) par rapport à l'héparine non fractionnée (HNF) chez les patients ayant un infarctus du myocarde avec élévation du segment ST (IMÉST). La validité externe des essais aléatoires et contrôlés peut être limitée par l'inclusion sélective de patients qui sont plus jeunes et en meilleure santé qu'au sein de la « véritable ¼ population. OBJECTIF : Évaluer l'innocuité et l'efficacité de l'ENOX par rapport à l'HNF chez des patients non sélectionnés ayant eu un IMÉST. MÉTHODOLOGIE : Les chercheurs ont comparé l'innocuité et l'efficacité de l'ENOX et de l'HNF chez des patients qui ont subi un IMÉST et ont reçu des fibrinolytiques dans 17 hôpitaux québécois en 2003. RÉSULTATS : Au total, 498 patients ayant subi un IMÉST ont reçu des anticoagulants systémiques, l'ENOX et l'HNF ayant été administrés chez 114 et 384 patients, respectivement. On ne constatait aucune différence à l'égard des caractéristiques de base des deux groupes de patients. Le taux d'événements cardiaques ou cérébraux négatifs majeurs en milieu hospitalier s'élevait à 11,4 % au sein du groupe prenant de l'ENOX, par rapport à 14,0 % dans celui prenant de l'HNF (P=0,51). Un décès en milieu hospitalier ou un infarctus non fatal s'est produit chez 7,9 % des patients qui avaient reçu de l'ENOX par rapport à 9,9 % de ceux qui avaient reçu de l'HNF (P=0,52). Des saignements majeurs se sont produits chez 4,4 % des patients qui avaient reçu de l'ENOX et 6,0 % de ceux qui avaient reçu de l'HNF (P=0,51). INTERPRÉTATION : En milieu réel, on ne remarquait aucune différence significative dans les taux de réactions néfastes en milieu hospitalier au sein du groupe prenant de l'ENOX par rapport à celui prenant de l'HNF. De plus vastes études d'observation pourraient mieux confirmer l'innocuité, l'efficacité et la durée optimale de l'administration d'ENOX chez des patients non sélectionnés ayant eu un IMÉST et étant traités par fibrinolyse.