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Study Shows Doses of Secondary Medications for Acute MI Are Often Too Low

August 21, 2013

“This raises the notion that should we be monitoring not just the class of drugs but also the doses and be mindful in practice of pushing doses to get to those higher therapeutic ranges,” said Christopher Cannon, MD, FACC.
New research suggests that current performance measures calling for the use of beta-blocker, statin and angiotensin converting enzyme inhibitor or angiotensin receptor blocker (ACE/ARB) therapy following acute myocardial infarction (MI) are incomplete. Data from two major multicenter registries found that while nearly all patients received the recommended drugs, only a minority of patients received "goal" doses of these agents, (defined as at least 75 percent of the target doses used in the clinical trials showing benefits of the drugs) according to a study published Aug. 21 in the Journal of the American College of Cardiology.

Researchers followed 6,748 acute MI patients for 12 months following discharge. Patients were treated at 31 U.S. hospitals enrolled in the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH), or both. While roughly 90 percent of patients were on the recommended secondary prevention regimen at discharge, two-thirds were prescribed doses less than 75 percent of the dose shown to be clinically effective in pivotal trials. Only 25 percent of patients who were under-prescribed at discharge were up-titrated to at least 75 percent of the target dose during the 12 months following discharge.

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The authors note that their results “may explain why the findings from clinical trials, where there was clear evidence of benefit for each medicine promoted by performance measures, have been discordant from those in clinical practice, where the impact of performance measures on reducing mortality has been underwhelming.”

Moving forward, the authors suggest that “performance measures may need to incorporate doses of medications to better achieve their goal of truly optimal medical therapy.” They also highlight a need to evaluate AMI in outpatient care, and note that “outpatient registries, such as PINNACLE, may provide additional insights into how best to track and optimize outpatient cardiac care.”

“In our efforts to offer high-quality care, we usually check to make sure that all appropriate, guideline-recommended medications are used, but really haven’t paid as much attention to the dose of these medications,” said Christopher Cannon, MD, FACC, Brigham and Women’s Hospital and Harvard Clinical Research Institute, Boston in an editorial comment. “Thus, this paper is a real eye-opener. This paper makes a major step forward and opens up a new way for us to try to maximize the benefit of these life-saving therapies for our patients.”

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