Clinical Research
Quality and Outcome
Beyond Medication Prescription as Performance Measures: Optimal Secondary Prevention Medication Dosing After Acute Myocardial Infarction

https://doi.org/10.1016/j.jacc.2013.04.102Get rights and content
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Objectives

The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI).

Background

Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown.

Methods

We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥75% target). Patients with contraindications were excluded from analyses for that medication.

Results

Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each.

Conclusions

Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.

Key Words

myocardial infarction
performance measures
secondary prevention

Abbreviations and Acronyms

ACEI
angiotensin-converting enzyme inhibitor
AMI
acute myocardial infarction
ARB
angiotensin II receptor blocker
CI
confidence interval
LDL-C
low-density lipoprotein cholesterol
LV
left ventricular
OR
odds ratio
SBP
systolic blood pressure

Cited by (0)

The TRIUMPH study was sponsored by a grant from the National Institutes of Health (National Heart, Lung, and Blood Institute): SCCOR Grant #P50HL077113. The PREMIER study (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) was principally supported by a grant from Cardiovascular Therapeutics, Inc., Palo Alto, California. The funding organizations did not play a role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; or preparation, review, or approval of the manuscript. Dr. Spertus is supported by a Clinical and Translational Science Award (1UL1RR033179); discloses industry relationships with Lilly, Genentech, Amgen, EvaHeart, and Amorcyte; and has served on the United Healthcare Scientific Advisory Board. Dr. Masoudi discloses a contract with the American College of Cardiology Foundation. Dr. Daugherty is supported by a Career Development Grant Award (K08HL103776) from the National Heart, Lung, and Blood Institute. Dr. Maddox is supported by a Career Development Grant Award from the Veterans Affairs Health Services Research and Development Service. Dr. Chan is supported by a Career Development Grant Award (K23HL102224) from the National Heart, Lung, and Blood Institute. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.