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Published on: May 14, 2013
Underutilization of antiplatelet and statin therapy after postoperative myocardial infarction following vascular
Andrea M Steely1, Peter W Callas2, Patrick K Hohl1
1Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt.
Insights
Adherence to cardiac medication guidelines after postoperative myocardial infarction (POMI) in vascular surgery patients is crucial. Prescribing antiplatelet and statin therapy at discharge significantly reduces late mortality in these high-risk individuals.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Clinical Outcomes
Background:
- Postoperative myocardial infarction (POMI) is a significant complication following vascular surgery.
- Adherence to evidence-based guidelines for antiplatelet and statin therapy post-POMI is essential for improving patient outcomes.
- Variations in care pathways may impact the long-term prognosis of patients experiencing POMI.
Purpose of the Study:
- To evaluate adherence to practice guidelines for antiplatelet and statin use in patients with POMI after vascular surgery.
- To determine the impact of cardiac medication (CM) use at discharge on late mortality.
- To investigate regional and procedure-specific variations in CM prescribing patterns.
Main Methods:
- Analysis of 1749 vascular surgery procedures with POMI from the Vascular Quality Initiative (VQI) registry (2005-2015).
- Assessment of discharge CM, including single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), and statin therapy.
- Utilized a proportional hazards model to analyze long-term mortality and controlled for confounding factors.
Main Results:
- 81% received aspirin, 38% P2Y12 inhibitor, 76% statin; 74% received combined antiplatelet and statin therapy.
- 26% of patients were not on combined antiplatelet and statin therapy at discharge.
- Combined antiplatelet and statin therapy was associated with improved survival (79% vs 69%) and lower late mortality (HR 0.72; P=.01).
- Significant regional variations in CM use (33%-100%) and procedure-specific differences were observed.
Conclusions:
- Regional and procedure-specific variations in cardiac medication regimens exist post-POMI in vascular surgery.
- Absence of combined antiplatelet and statin therapy at discharge is linked to higher late mortality.
- Optimizing CM prescribing post-POMI represents a critical area for quality improvement in vascular surgery care.
Objective:
The objective of this study was to investigate adherence to practice guidelines for antiplatelet and statin use after postoperative myocardial infarction (POMI) and its effect on late mortality following vascular surgery in a multicenter registry.
Methods:
Antiplatelet and statin use was examined in 1749 vascular surgery procedures with POMI within the Vascular Quality Initiative (VQI) from 2005 to 2015. Our primary aim was to assess cardiac medication (CM) use at discharge, defined as (1) single antiplatelet therapy (SAPT; aspirin or P2Y12 inhibitor) or dual antiplatelet therapy (DAPT; aspirin and P2Y12 inhibitor) and (2) statin therapy. Long-term mortality in patients with POMI was analyzed on the basis of discharge CM. A proportional hazards model was developed to control for factors associated with mortality. Regional differences in CM use at discharge after POMI were compared.
Results:
Overall discharge CM use after POMI included aspirin (81%), P2Y12 inhibitor (38%), statin therapy (76%), and combined antiplatelet and statin (74%). At discharge, 26% of patients were not receiving combined antiplatelet and statin therapy. SAPT (50%) was more common than DAPT (35%; P < .001). Patients with POMI undergoing carotid endarterectomy were more likely to be discharged on CM (80%) compared with patients undergoing infrainguinal bypass (78%), suprainguinal bypass (72%), endovascular aneurysm repair (71%), and open abdominal aortic aneurysm repair (59%; P < .001). Patients receiving SAPT or DAPT plus statin therapy had improved survival (79%) compared with those receiving noncombination or no therapy (69%) with mean follow-up of 5.5 years and 4.9 years, respectively (log-rank, P = .001). After adjustment for covariates including preoperative medications, treatment with SAPT or DAPT plus statin at discharge was associated with lower late mortality compared with noncombination or no therapy (hazard ratio, 0.72; 95% confidence interval, 0.56-0.93; P = .01). Regional variation in CM at discharge following POMI was also observed with a range of 33% to 100% (P = .05).
Conclusions:
Within the VQI, regional and procedure-specific variation exists in CM regimen after POMI following vascular surgery. Absence of combined antiplatelet and statin therapy at discharge after POMI was associated with higher late mortality and represents an area for quality improvement in the care of these patients.
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