doi: 10.1161/01.CIR.0000112577.69066.CB
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
(Circulation. 2004;109:745-749.)
© 2004 American Heart Association, Inc.
Clinical Investigation and Reports |
Impact of Combination Evidence-Based Medical Therapy on Mortality in Patients With Acute Coronary Syndromes
From the University of Michigan, Ann Arbor, Mich.
Correspondence to Debabrata Mukherjee, MD, Division of Cardiology, University of Michigan Health System, University Hospital, TC B1 226, 1500 E Medical Center Drive, Ann Arbor, MI 48103-0311. E-mail dmukherj{at}umich.edu
Received August 4, 2003; de novo received September 3, 2003; revision received October 16, 2003; accepted October 23, 2003.
Background— Several individual pharmacological agents, such as antiplatelet drugs, ß-blockers, ACE inhibitors, and lipid-lowering agents, have proven efficacy in reducing mortality in patients with acute coronary syndromes. However, the impact of the combination of these agents on clinical outcomes has not been studied before.
Methods and Results— A total of 1358 consecutive patients presenting with acute coronary syndromes between January 1999 and March 2002 were identified, and data on baseline demographics, comorbidities, and in-hospital management were collected. On the basis of discharge use of evidence-based therapies, we created a composite appropriateness score depending on the number of the drugs used divided by the number of the drugs potentially indicated for each patient. The impact of the composite score on 6-month mortality was analyzed using a risk-adjusted logistic regression model. The odds ratio for death for all indicated medications used (appropriateness level IV) versus none of the indicated medications used (appropriateness level 0) was 0.10 (95% CI, 0.03 to 0.42; P<0.0001); similarly, odds ratio for appropriateness level III versus level 0 was 0.17 (95% CI, 0.04 to 0.75; P=0.0018), odds ratio for appropriateness level II versus level 0 was 0.18 (95% CI, 0.04 to 0.77; P=0.01), and odds ratio for appropriateness level I versus level 0 was 0.36 (95% CI, 0.08 to 1.75; P=0.20).
Conclusions— Use of combination evidence-based medical therapies was independently and strongly associated with lower 6-month mortality in patients with acute coronary syndromes. Such therapies, most of which are generic and inexpensive today, seem to offer a marked survival advantage compared with patients in whom such therapies are omitted.
Key Words: coronary disease • mortality • survival • myocardial infarction
Related Article:
Circulation 2004 109: 698-700.
This article has been cited by other articles:
 |
|
 |
|
  K. M. Nielsen, O. Faergeman, A. Foldspang, and M. L. Larsen Cardiac rehabilitation: health characteristics and socio-economic status among those who do not attend Eur J Public Health, July 9, 2008; (2008) ckn060v1. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. S. Chung, Lin Guo, D. E. Casey Jr, C. Bartone, S. Menon, S. Saghir, A. Mital, and D. J. Kereiakes Relationship of a Quality Measure Composite to Clinical Outcomes for Patients With Heart Failure American Journal of Medical Quality, June 1, 2008; 23(3): 168 - 175. [Abstract] [PDF]
|
|
|
|
 |
|
 M. Singh, J. White, D. Hasdai, P. K. Hodgson, P. B. Berger, E. J. Topol, R. M. Califf, and D. R. Holmes Jr Long-Term Outcome and its Predictors Among Patients With ST-Segment Elevation Myocardial Infarction Complicated by Shock: Insights From the GUSTO-I Trial J. Am. Coll. Cardiol., October 30, 2007; 50(18): 1752 - 1758. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. G. Steg Overview of large morbidity/mortality trials with ivabradine: focus on the BEAUTIfUL study Eur. Heart J. Suppl., September 1, 2007; 9(suppl_F): F15 - F19. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. L. Anderson, C. D. Adams, E. M. Antman, C. R. Bridges, R. M. Califf, D. E. Casey Jr, W. E. Chavey II, F. M. Fesmire, J. S. Hochman, T. N. Levin, et al. ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine J. Am. Coll. Cardiol., August 14, 2007; 50(7): e1 - e157. [Full Text] [PDF]
|
|
|
|
 |
|
 Authors/Task Force Members, J.-P. Bassand, C. W. Hamm, D. Ardissino, E. Boersma, A. Budaj, F. Fernandez-Aviles, K. A.A. Fox, D. Hasdai, E. M. Ohman, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes: The Task Force for the Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of the European Society of Cardiology Eur. Heart J., July 1, 2007; 28(13): 1598 - 1660. [Full Text] [PDF]
|
|
|
|
 |
|
 P Wong, A Ramsewak, S Murray, A Robinson, D Robinson, and E Rodrigues Effects of comorbidity and hospital care on 6-month mortality in patients with elevated cardiac troponin T Postgrad. Med. J., May 1, 2007; 83(979): 332 - 337. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. Goyal, J. H. Alexander, G. E. Hafley, S. H. Graham, R. H. Mehta, M. J. Mack, R. K. Wolf, L. H. Cohn, N. T. Kouchoukos, R. A. Harrington, et al. Outcomes Associated With the Use of Secondary Prevention Medications After Coronary Artery Bypass Graft Surgery Ann. Thorac. Surg., March 1, 2007; 83(3): 993 - 1001. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 N F Murphy, S Stewart, C L Hart, K MacIntyre, D Hole, and J J V McMurray A population study of the long-term consequences of Rose angina: 20-year follow-up of the Renfrew-Paisley study Heart, December 1, 2006; 92(12): 1739 - 1746. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M Heras, H Bueno, A Bardaji, A Fernandez-Ortiz, H Marti, J Marrugat, and on behalf of the DESCARTES Investigators Magnitude and consequences of undertreatment of high-risk patients with non-ST segment elevation acute coronary syndromes: insights from the DESCARTES Registry Heart, November 1, 2006; 92(11): 1571 - 1576. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. J. Kereiakes and E. M. Antman Clinical Guidelines and Practice: In Search of the Truth J. Am. Coll. Cardiol., September 19, 2006; 48(6): 1129 - 1135. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. Collinson, A. Bakhai, A. Taneja, D. Wang, and M.D. Flather Admission ECG predicts long-term outcome in acute coronary syndromes without ST elevation QJM, September 1, 2006; 99(9): 601 - 607. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. G. Steg and D. Tchetche Pharmacologic management of stable angina: role of ivabradine Eur. Heart J. Suppl., September 1, 2006; 8(suppl_D): D16 - D23. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. M. Jani, C. Montoye, R. Mehta, A. L. Riba, A. C. DeFranco, R. Parrish, S. Skorcz, P. L. Baker, J. Faul, B. Chen, et al. Sex Differences in the Application of Evidence-Based Therapies for the Treatment of Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice Projects in Michigan. Arch Intern Med, June 12, 2006; 166(11): 1164 - 1170. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. Daly, F. Clemens, J. L. Lopez-Sendon, L. Tavazzi, E. Boersma, N. Danchin, F. Delahaye, A. Gitt, D. Julian, D. Mulcahy, et al. The impact of guideline compliant medical therapy on clinical outcome in patients with stable angina: findings from the Euro Heart Survey of stable angina Eur. Heart J., June 1, 2006; 27(11): 1298 - 1304. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Tricoci, M. T. Roe, J. Mulgund, L. K. Newby, S. C. Smith Jr, C. V. Pollack Jr, D. J. Fintel, C. P. Cannon, D. L. Bhatt, W. B. Gibler, et al. Clopidogrel to Treat Patients With Non-ST-Segment Elevation Acute Coronary Syndromes After Hospital Discharge. Arch Intern Med, April 10, 2006; 166(7): 806 - 811. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 L. K. Newby, N. M. Allen LaPointe, A. Y. Chen, J. M. Kramer, B. G. Hammill, E. R. DeLong, L. H. Muhlbaier, and R. M. Califf Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease Circulation, January 17, 2006; 113(2): 203 - 212. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. W. Mahaffey, M. Cohen, J. Garg, E. Antman, N. S. Kleiman, S. G. Goodman, L. G. Berdan, C. J. Reist, A. Langer, H. D. White, et al. High-Risk Patients With Acute Coronary Syndromes Treated With Low-Molecular-Weight or Unfractionated Heparin: Outcomes at 6 Months and 1 Year in the SYNERGY Trial JAMA, November 23, 2005; 294(20): 2594 - 2600. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. A. Jaber, R. J. Lennon, V. Mathew, D. R. Holmes Jr, A. Lerman, and C. S. Rihal Application of Evidence-Based Medical Therapy Is Associated With Improved Outcomes After Percutaneous Coronary Intervention and Is a Valid Quality Indicator J. Am. Coll. Cardiol., October 18, 2005; 46(8): 1473 - 1478. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. F. Hernandez, E. J. Velazquez, S. D. Solomon, R. Kilaru, R. Diaz, C. M. O'Connor, G. Ertl, A. P. Maggioni, J.-L. Rouleau, W. van Gilst, et al. Left Ventricular Assessment in Myocardial Infarction: The VALIANT Registry Arch Intern Med, October 10, 2005; 165(18): 2162 - 2169. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. A. Eagle, C. K. Montoye, A. L. Riba, A. C. DeFranco, R. Parrish, S. Skorcz, P. L. Baker, J. Faul, S. M. Jani, B. Chen, et al. Guideline-Based Standardized Care Is Associated With Substantially Lower Mortality in Medicare Patients With Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice (GAP) Projects in Michigan J. Am. Coll. Cardiol., October 4, 2005; 46(7): 1242 - 1248. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. T. Roe, E. D. Peterson, Y. Li, C. V. Pollack Jr, R. H. Christenson, W. F. Peacock, F. M. Fesmire, L. K. Newby, R. L. Jesse, J. W. Hoekstra, et al. Relationship Between Risk Stratification by Cardiac Troponin Level and Adherence to Guidelines for Non-ST-Segment Elevation Acute Coronary Syndromes Arch Intern Med, September 12, 2005; 165(16): 1870 - 1876. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. P. Giugliano and E. Braunwald The Year in Non--ST-Segment Elevation Acute Coronary Syndromes J. Am. Coll. Cardiol., September 6, 2005; 46(5): 906 - 919. [Full Text] [PDF]
|
|
|
|
|
|
P. Gabriel Steg and D. Himbert Unmet medical needs and therapeutic opportunities in stable angina Eur. Heart J. Suppl., September 1, 2005; 7(suppl_H): H7 - H15. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Le May, G. A. Wells, M. Labinaz, R. F. Davies, M. Turek, D. Leddy, J. Maloney, T. McKibbin, B. Quinn, R. S. Beanlands, et al. Combined Angioplasty and Pharmacological Intervention Versus Thrombolysis Alone in Acute Myocardial Infarction (CAPITAL AMI Study) J. Am. Coll. Cardiol., August 2, 2005; 46(3): 417 - 424. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. T. Roe, L. S. Parsons, C. V. Pollack Jr, J. G. Canto, H. V. Barron, N. R. Every, W. J. Rogers, E. D. Peterson, and for the National Registry of Myocardial Infarction Quality of Care by Classification of Myocardial Infarction: Treatment Patterns for ST-Segment Elevation vs Non-ST-Segment Elevation Myocardial Infarction Arch Intern Med, July 25, 2005; 165(14): 1630 - 1636. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. Baruch and R. A. Phillips Quality: The Need for Intelligent Efforts Arch Intern Med, July 11, 2005; 165(13): 1455 - 1456. [Full Text] [PDF]
|
|
|
|
|
|
D. Mukherjee Optimizing management of patients with coronary artery disease: how do we get there? Eur. Heart J., June 2, 2005; 26(12): 1147 - 1149. [Full Text] [PDF]
|
|
|
|
|
|
F. Schiele, N. Meneveau, M. F. Seronde, F. Caulfield, R. Fouche, G. Lassabe, D. Baborier, P. Legalery, J.-P. Bassand, and on behalf of the Reseau de Cardiologie de Franche Compliance with guidelines and 1-year mortality in patients with acute myocardial infarction: a prospective study Eur. Heart J., May 1, 2005; 26(9): 873 - 880. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D Mukherjee, J Fang, E Kline-Rogers, R Otten, and K A Eagle Impact of combination evidence based medical treatment in patients with acute coronary syndromes in various TIMI risk groups Heart, March 1, 2005; 91(3): 381 - 382. [Full Text] [PDF]
|
|
|
|
|
|
A. S. Leon, B. A. Franklin, F. Costa, G. J. Balady, K. A. Berra, K. J. Stewart, P. D. Thompson, M. A. Williams, and M. S. Lauer Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease: An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation Circulation, January 25, 2005; 111(3): 369 - 376. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. J. Wolk, C. N. Bairey Merz, and P. D. Thompson President's page: The promise of prevention: So, why aren't all cardiologists "preventive"? J. Am. Coll. Cardiol., November 16, 2004; 44(10): 2082 - 2084. [Full Text] [PDF]
|
|
|
|
|
|
S. R. Kapadia and D. J. Moliterno Did we enjoy the debate but forget the patient? J. Am. Coll. Cardiol., August 18, 2004; 44(4): 775 - 777. [Full Text] [PDF]
|
|
|
|
|
|
G. Permanyer-Miralda, I. Ferreira, A. Ribera, D. Mukherjee, J. Fang, S. Chetcuti, M. Moscucci, E. Kline-Rogers, and K. A. Eagle Optimal Therapy for Acute Coronary Syndromes: The More the Better? * Response Circulation, August 3, 2004; 110(5): e52 - e52. [Full Text] [PDF]
|
|
|
|
|
|
D. J. Kereiakes and J. T. Willerson Doctors and Hospitals: Healthcare's Rubik's Cube Circulation, May 25, 2004; 109(20): 2381 - 2385. [Full Text] [PDF]
|
|
|
|
|
|
H. D. White and J. T. Willerson We Must Use the Knowledge That We Have to Treat Patients With Acute Coronary Syndromes Circulation, February 17, 2004; 109(6): 698 - 700. [Full Text] [PDF]
|
|