Follow-up Dosing of Guideline-Indicated Medications After Myocardial Infarction: Insights from the Acute Myocardial
Oswald Chen1, Todd A Wilson1,2, Matthew T Bennett3
1Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
Insights
Patients with myocardial infarction (MI) and reduced ejection fraction often don't receive target medication doses. Adherence to medication dosing did not improve LVEF or lead to more imaging.
Area of Science:
- Cardiology
- Clinical Quality Improvement
- Pharmacotherapy
Background:
- Optimal medication dosing post-myocardial infarction (MI) improves outcomes and indicates quality care.
- Reduced left ventricular ejection fraction (LVEF) after MI necessitates careful medication management.
- This study examines medication adherence and its impact on LVEF and follow-up imaging.
Purpose of the Study:
- To assess adherence to target doses of core cardiac medications in MI patients with reduced LVEF.
- To determine if adherence to medication dosing is linked to follow-up LVEF imaging.
- To investigate the association between medication dosing and LVEF changes within six months.
Main Methods:
- The Acute Myocardial Infarction Quality Assurance (AMIQA) Canada study enrolled 501 MI patients with LVEF ≤ 45%.
- Patients were followed for 6 months, assessing use and dosing of beta-blockers, ACE inhibitors, ARBs, MRAs, and statins.
- LVEF changes were compared between patients receiving ≥50% vs <50% of target medication doses.
Main Results:
- At 6 months, mean target dose adherence was ≤50% for beta-blockers, ACE inhibitors, and ARBs.
- Mineralocorticoid receptor antagonists (MRAs) adherence was 70.8%, and 86.8% received high-intensity statins.
- Only MRA use correlated with follow-up LVEF reassessment; target dosing did not impact LVEF changes.
Conclusions:
- Most MI patients with reduced LVEF do not achieve target medication doses, except for statins.
- Follow-up medication dosing adherence was not associated with LVEF reassessment or improvement.
- Quality improvement efforts need tailored strategies for medication dosing and follow-up imaging adherence.
Background:
Achieving the target doses of indicated medications after myocardial infarction (MI) is associated with improved outcomes and is a marker of the quality of care. We studied the use and follow-up dosing of core cardiac medications among patients with MI complicated by depressed left ventricular ejection fraction (LVEF). Our objective was to determine whether adherence to evidence-based medication dosing is associated with receipt of follow-up LVEF imaging or progression of LVEF within 6 months of follow-up care.
Methods:
The Acute Myocardial Infarction Quality Assurance (AMIQA) Canada study enrolled 501 patients (mean age 63 years; 22.6% female) with acute MI and LVEF ≤ 45%, from 14 Canadian centres. Patients were followed for 6 months to determine their adherence to post-MI follow-up recommendations. We assessed use and dosing of beta-blockers, angiotension-converting enzyme inhibitors, angiotensin II receptor blockers, mineralocorticoid receptor antagonists (MRAs), and statins, and compared changes in LVEF among those taking ≥50% vs < 50% of the target dose in the follow-up period.
Results:
At 6 months, the mean percent target dose was ≤ 50% for beta-blockers, angiotension-converting enzyme inhibitors, and angiotensin II receptor blockers, but it was 70.8% ± 46.9% for MRAs, and 86.8% received high-intensity statin. Only use of MRA was associated with follow-up LVEF reassessment (P < 0.001). Receiving ≥ 50% of the target dose was not associated with changes in LVEF.
Conclusions:
Except for statins, most patients were not receiving target doses of indicated medications after MI with reduced LVEF. Follow-up dosing was not associated with LVEF reassessment or improvement in LVEF. Future quality-improvement initiatives may require distinct strategies for improving adherence to recommendations for medication dosing vs follow-up imaging.
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