GRACE - increased medical therapy use in AMI patients

GRACE shows 'encouraging' increased medical therapy use in AMI patients

By Caroline Price

14 September 2007

Arch Intern Med 2007; 167: 1766-1773


MedWire News: Use of both single and combination medical therapy in patients hospitalized with acute myocardial infarction (AMI) increased from 2000 through 2005, suggest results from the Global Registry of Acute Coronary Events (GRACE).


Robert Goldberg (Brown University, Providence, Rhode Island, USA) and colleagues explored use of four effective cardiac medications, namely aspirin, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and lipid-lowering agents at discharge in 26,413 adult men and women without contraindications to any of the drugs.


Increases were seen in singular use of three out of the four therapies, particularly that of statins, which increased from 45% of patients in 2000 to 85% in 2005. ACE inhibitor use increased from 63% to 77%, and beta blocker use from 83% to 91%.


There was little or no increase in aspirin over time, since this therapy was already being used in most AMI hospital survivors (around 95%).


There were marked increases in the use of multiple medications, particularly in use of all four combined, which increased from 23% of patients in the first half of 2000 to 58% in the second half of 2005.


Virtually identical trends were seen in the use of single and combination therapy in ST-elevation myocardial infarction (STEMI) and non-STEMI patients.


Further analysis revealed that patients of advancing age (=65 years), women, and those with a history of heart failure or stroke, who were hospitalized in participating centers in Argentina and Brazil, or developed atrial fibrillation during hospitalization, were more likely to be discharged receiving one, two, or three instead of all four medications.


Similar factors were associated with underuse of all four medications when STEMI or non-STEMI patients were studied separately, and with use of relatively few compared with three medications, the authors say in the Archives of Internal Medicine.


However, they conclude: "Despite these encouraging trends, gaps in the use of combination medical therapies continue to exist. Closing this gap will require novel and concerted efforts."


They say increased understanding and minimization of drug interactions, increased use of combination tablets, and education about the differences between "polypharmacy" and effective combination therapy are needed to this end.

LINNK:
Free abstract

Swiss Interventional Study on Silent Ischaemia type I

Effects of anti-ischaemic drug therapy in silent myocardial ischaemia type I: the Swiss Interventional Study on Silent Ischaemia type I (SWISSI I): a randomized, controlled pilot study


Paul Erne1, Andreas W. Schoenenberger2, Michel Zuber1, Dieter Burckhardt3, Wolfgang Kiowski4, Paul Dubach5, Therese Resink3 and Matthias Pfisterer3,*



Aims: To determine the effect of anti-ischaemic drug therapy on long-term outcomes of asymptomatic patients without coronary artery disease (CAD) history but silent exercise ST-depression.


Methods and results: In a randomized multicentre trial, 263 of 522 asymptomatic subjects without CAD but at least one CAD risk factor in whom silent ischaemia by exercise ECG was confirmed by stress imaging were asked to participate. The 54 (21%) consenting patients were randomized to anti-anginal drug therapy in addition to risk factor control (MED, n = 26) or risk factor control-only (RFC, n = 28). They were followed yearly for 11.2 ± 2.2 years. During 483 patient-years, cardiac death, non-fatal myocardial infarction, or acute coronary syndrome requiring hospitalization or revascularization occurred in 3 (12%) of MED vs. 17 (61%) of RFC patients (P < 0.001). In addition, MED patients had consistently lower rates of exercise-induced ischaemia during follow-up, and left ventricular ejection fraction remained unchanged (–0.7%, P = 0.597) in contrast to RFC patients in whom it decreased over time (–6.0%, P = 0.006).

Conclusion: Anti-ischaemic drug therapy and aspirin seem to reduce cardiac events in subjects with asymptomatic ischaemia type I. In such patients, exercise-induced ST-segment depression should be verified by stress imaging; if silent ischaemia is documented, anti-ischaemic drug therapy and aspirin should be considered


Eur Heart J 2007; 28: 2110-2117

Commentaries:

Cohn Type I refers to asymptomatic individuals without known coronary artery disease (CAD) and Cohn Types II and III to patients with known CAD. Those with prior myocardial infarctions (MIs) who are asymptomatic are Type II, and those with CAD and both silent and symptomatic ischaemic episodes are Type III.1 In the last decade a dedicated group of Swiss cardiologists led by Dr Mathias Pfister of the Basel University Hospital have conducted a long-term series of clinical studies involving patients with Types I and II silent ischaemia. By providing a ‘new look’ at the syndrome of silent ischaemia they have contributed important clinical data to aid in its management. They have now described the results of anti-ischaemia drug therapy in Type I patients (studied in their SWISS I trial);2 their SWISS II data dealing with Type 2 patients and also recently published3 will be commented on later in this editorial.