04 May Majority of Myocardial Infarction Patients Do Not Achieve Risk Factor Control
Medical Research: What is the background for this study?
Dr. Paixao: Despite advances in cardiovascular prevention, coronary heart disease remains a major cause of morbidity and mortality. Understanding risk factor burden and control as well as perceived risk prior to acute myocardial infarction (MI) presentation may identify opportunities for system-based interventions to promote adherence to evidence based recommendations and improve overall cardiovascular health.
Medical Research: What are the main findings?
Dr. Paixao: Our study assessed predicted risk and risk factor control prior to Myocardial Infarction (MI) presentation in 443,117 patients included in the NCDR ACTION Registry-GWTG. Only 36.1% of patients met all assessed risk factor control metrics (i.e. LDL cholesterol, non-HDL cholesterol, nonsmoking status and aspirin use among those with prior cardiovascular disease). Risk factor control was suboptimal in the primary and secondary prevention groups.
Prior cardiovascular disease was present in 41.6% of patients presenting with an acute MI. Among those without prior cardiovascular disease or diabetes, only 13.4% were classified as high risk based on the Framingham Risk Score.
Medical Research: How did you define LDL and non-HDL cholesterol goals?
Dr. Paixao: Since our study included patients presenting between January 1, 2007 and November 11, 2013, we used the risk stratification model and cholesterol goals of the then prevailing Third Adult Treatment Panel (ATPIII). As an exploratory analysis, we also assessed statin eligibility according to the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines on the Treatment of Blood Cholesterol.
Medical Research: Have you compared statin eligibility according to ATPIII and the 2013 ACC/AHA guidelines?
Dr. Paixao: Applying ATPIII recommendations, only 60.8% of patients would be eligible for treatment with a statin medication prior to MI presentation. On the other hand, 89.9% of patients would qualify for statin treatment according to the 2013 ACC/AHA guidelines. Interestingly, a similar number of patients (81.4%) would be statin eligible according to the ATPIII optional LDL cholesterol goals.
Medical Research: What should clinicians and patients take away from your report?
Dr. Paixao: In a large multicenter registry with >400,000 acute MI patients, risk factor control was deficient across the spectrum of cardiovascular risk. Our findings indicate the need for better strategies to improve adherence to preventive targets for both primary and secondary prevention. Nationwide system-based interventions will likely be necessary to improve risk factor control.
According to ATPIII recommendations, few MI patients without diabetes or prior CVD would be classified as high risk (13.4%) prior to presentation. In this primary prevention group, many would not have met ATPIII statin eligibility criteria prior to MI presentation (62.1%). Even though our study includes only MI patients and was not designed to compare the old and new cholesterol guidelines, our findings support the adoption of more aggressive treatment recommendations such as the ATPIII optional LDL goals or the 2013 ACC/AHA guidelines.
I also think our study gives some perspective to the debate over the 2013 ACC/AHA guidelines. Even applying the less aggressive ATPIII treatment recommendations, the vast majority of MI patients did not meet all assessed risk factor control metrics. This large gap between guideline recommendations and achieved risk factor control among MI patients suggests that we should perhaps present an “united front” and heavily invest in promoting adherence to preventive measures.
Risk Factor Burden and Control at the Time of Admission in Patients with Acute Myocardial Infarction: Results from the National Cardiovascular Data Registry
Andre R.M. Paixao, MD ,Jonathan R. Enriquez, MD, Tracy Y. Wang, MD, MHS, MSc ,Shuang Li, MS, Jarett D. Berry, MD, MS ,Amit Khera, MD, MSc ,Sandeep R. Das, MD, MPH James A. de Lemos, MD,Michael C. Kontos, MD
MedicalResearch.com Interview with: Andre Paixao, MD, Division of Cardiology, Emory University, & Atlanta, GA, 30322. (2015). Majority of Myocardial Infarction Patients Did Not Achieve Risk Factor Control