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Guideline-directed therapy after MI decreases mortality risk in older patients
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Older patients who were predominantly frail and treated with guideline-recommended medications after an MI had a decreased risk for mortality, according to a study published in Circulation: Cardiovascular Quality and Outcomes.
This approach to treatment did not result in a different in rehospitalization, according to the study.
“Based on our findings, using more medications to prevent another heart attack may be useful for vulnerable older adults who wish to live longer,” Andrew R. Zullo, PharmD, PhD, assistant professor of health services, policy and practice at Brown University in Providence, Rhode Island, said in a press release. “However, since using more medications may interfere with older adults’ ability to do their daily activities, more medications should not be taken by older adults who wish to maintain their independence and daily functioning rather than live longer. Using more medications after a heart attack does not simply improve all health outcomes.”
Nursing home residents
In this retrospective cohort study, researchers analyzed data from 4,787 patients (mean age, 84 years; 68% women) who lived in a nursing home and were hospitalized for an acute MI between 2007 and 2010. Data were obtained from Medicare data sets and U.S. Minimum Data Set 2.0. These patients had not taken beta-blockers, antiplatelet medications, statin therapy or renin-angiotensin-aldosterone system inhibitor medications at least 4 months before the acute MI.
The outcomes of interest were all-cause rehospitalization, death and functional decline. Follow-up was conducted starting at 14 days after hospital discharge for 90 days.
Of the patients in the study, 38.1% received one medication, 32.8% received two medications and 29% received three or four medications after an acute MI.
During follow-up, 10.6% of patients died, 25.6% were rehospitalized and 17.1% experienced functional decline. A significant decrease in mortality was seen in patients who were prescribed three or four medications vs. those prescribed one medication after an acute MI (OR = 0.74; 95% CI, 0.57-0.97). There was no significant difference in all-cause rehospitalization (OR = 0.97; 95% CI, 0.8-1.17) or functional decline (OR = 1.12; 95% CI, 0.89-1.4).
Patients who were prescribed two medications after an acute MI instead of one medication did not have a significant decrease in functional decline (OR = 1.04; 95% CI, 0.85-1.28), mortality (OR = 0.98; 95% CI, 0.79-1.22) or rehospitalization (OR = 1; 95% CI, 0.85-1.19).
Association with functional decline
When antiplatelet drugs were excluded from the exposure definition in a stability analysis, the prescription of two medications (OR = 1.27; 95% CI, 1.07-1.53) or three medications (OR = 1.3; 95% CI, 1.03-1.63) was significantly linked to functional decline.
“Additional research is necessary to evaluate whether more secondary prevention medication use among frail, older adults truly does result in functional harms and how information on type of infarct may influence the results,” Zullo and colleagues wrote. “While residual confounding remains a concern and plausible alternative explanation for all findings, the results suggest that use of more secondary prevention medications after [acute] MI is indicated for frail, older adults who wish to maximize their longevity.”
In a related editorial, Susan K. Bowles, PharmD, MSc, assistant professor at Dalhousie University College of Pharmacy in Halifax, Nova Scotia, and Melissa K. Andrew, MD, PhD, associate professor in the division of geriatric medicine at Dalhousie University, wrote: “Zullo et al has highlighted the need to consider risk for medication-related harms in the context of potential benefits. It also emphasizes the need for appropriate monitoring of medications in the nursing home environment, as well as addressing medication-related harms, should they arise.” – by Darlene Dobkowski
Disclosures: The authors, Bowles and Andrew report no relevant financial disclosures.
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