March 12, 2020
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Guideline adherence after acute MI improves long-term survival

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Matthew D. Solomon

Patients who adhered to guideline-recommended medical therapy, lifestyle changes and risk factor control after an acute MI had improved long-term survival, according to a study published in the Journal of the American Heart Association.

“Our data show that to get the maximum benefit after a heart attack, all guidelines must be followed,” Matthew D. Solomon, MD, PhD, cardiologist at Kaiser Permanente in Oakland, California, and an adjunct investigator for Kaiser Permanente Division of Research, told Healio. “Even one less than the maximum number was associated with reduced long-term survival. That was a surprising finding, that there were no diminishing returns even at high levels of guideline adherence. We thought patients who adhered to most recommendations might do as well as those who achieved all of them, but that’s not what we found.”

Researchers analyzed data from patients with acute MI between 2008 and 2014 who survived at least 30 days (n = 25,778; mean age, 69 years; 36% women) or 90 days after the event (n = 24,200; mean age, 68 years; 36% women). All patients were treated at Kaiser Permanente Northern California.

The primary exposure was patient-level adherence to guideline-recommended treatment goals at 30 and 90 days. The seven guideline recommendations of interest included the filled prescriptions for an ACE inhibitor or angiotensin receptor blocker, a P2Y12 antiplatelet agent, a beta-blocker, a lipid medication, in addition to not smoking after discharge, an outpatient BP less than 140/90 mm Hg and LDL less than 100 mg/dL in those who survived 90 days after discharge. The primary outcome was all-cause death.

Guideline adherence was high; at 30 days, 35% of patients met five out of six guideline recommendations and 34% met six out of six recommendations. At 90 days, 31% met six out of six recommendations and 23% met all seven studied recommendations.

Compared with meeting zero to three guideline recommendations, greater guideline adherence was independently linked to improved survival, as observed in patients who met seven recommendations (HR = 0.57; 95% CI, 0.49-0.66) and six recommendations (HR = 0.69; 95% CI, 0.61-0.78) at 90 days. These results were similar at 30 days.

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HR for mortality in patients who adhered to 0 to 3 guideline compared with those who adhered to six or seven.

There was a significant favorable association between mortality and adherence to each additional guideline recommendation at 30 days (HR = 0.89; 95% CI, 0.86-0.92) and 90 days (HR = 0.92; 95% CI, 0.9-0.94).

“Knowledge is power,” Solomon said in an interview. “Just having data like these that doctors can share with their patients might provide the needed motivation for patients to adhere to all of their doctor’s recommendations and get the best start on their long-term journey toward heart health and wellness. This can also inform health systems and cardiology societies to further promote systematic programs like cardiac rehab, which are crucial after a heart attack to help ensure patients are doing everything possible to reduce the chance of a future heart attack and prolong their lives.” – by Darlene Dobkowski

For more information:

Matthew D. Solomon, MD, PhD, can be reached at matthew.d.solomon@kp.org.

Disclosures: The study was funded by a research grant from Genentech and research support from The Permanente Medical Group Delivery Science and Physician Researcher Programs. The authors report no relevant financial disclosures.