Medication persistence and mortality in ST-elevation myocardial infarction patients with and without standard...

We examine persistence with secondary prevention medication and longer-term mortality in a population-level cohort of ST-elevation myocardial infarction (STEMI) patients with and without standard modifiable cardiovascular risk factors (SMuRFs; hypertension, diabetes, hypercholesterolaemia, smoking).

We utilized landmark analysis to study 65 059 first-time STEMI patients from the SWEDEHEART registry who were prescribed aspirin, lipid-lowering therapy (LLT), renin-angiotensin-aldosterone system (RAAS) inhibitors, or beta-blockers at hospital discharge. Persistence was assessed as a binary variable in patients alive 12 months after first dispensation (initiation, the landmark). The primary outcome was all-cause mortality 3 years after the 12-month landmark. Multivariable logistic regression models and Kaplan-Meier analyses were used to compare persistence, and Cox proportional hazards models to assess the impact of persistence on mortality. At 4 years after pharmacotherapy initiation, >50% of patients had discontinued prescribed aspirin, LLT, RAAS inhibitor, or beta-blocker. SMuRF-less patients were less likely to receive medications at hospital discharge; however, if prescribed, they were more likely to be persistent with aspirin and LLT at 12 months compared to SMuRF-positive patients. Discontinuing aspirin, LLT, or RAAS inhibitors within 12 months after initiation was associated with increased all-cause mortality 3 years later in both groups (HR between 1.45 and 2.02). Beta-blocker discontinuation was not associated with mortality in either group.

Persistence with secondary prevention medication declined rapidly in this cohort. The increased longer-term mortality associated with 12-month non-persistence highlights the need to better understand drivers of medication discontinuation, and to work with patients and clinicians to support consistent use of guideline-recommended medications, regardless of risk factor status.