Original ArticleResidual risk for coronary heart disease events and mortality despite intensive medical management after myocardial infarction
Introduction
Over 500,000 United States (US) adults are discharged annually after a myocardial infarction (MI).1 To prevent recurrent events, current guidelines recommend a strategy of comprehensive secondary prevention, including high-intensity statins, beta-blockers, renin-angiotensin-aldosterone system inhibitors, and dual antiplatelet therapy.2, 3, 4, 5, 6, 7, 8, 9 Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) have the strongest indications for use in those with high-risk features but can be considered in all other patients after MI.2,3,7,8 The remaining agents are indicated in all individuals after MI in the absence of contraindications.2,3,7, 8, 9 Although not all patients have indications for each of these medications, people who receive medications from each of these classes represent a subgroup that is being as intensively medically managed as is feasible with traditional strategies.
In addition to the traditional medications discussed previously, there are new agents that could further reduce the risk for cardiovascular events including ezetimibe, proprotein convertase subtilisin/kexin type 9 inhibitors, glucagon-like peptide 1 receptor agonists, sodium-glucose cotransporter 2 inhibitors, and icosapent ethyl.9, 10, 11, 12, 13, 14, 15 To provide guidance to clinicians, the National Lipid Association has recently published 2 statements on the use of proprotein convertase subtilisin/kexin type 9 inhibitors and icosapent ethyl in patients with cardiovascular disease.15,16 This statement, and others, emphasizes that to direct these additional therapies to individuals with MI who are most likely to benefit, it is first necessary to quantify the residual risk for CHD events after an MI in those who are as intensively medically managed as is feasible with traditional strategies and identify sub-groups who are at particularly increased risk.9,15,16,17
Prior analyses that have examined residual risk after MI, including those in the National Lipid Association statements,15,16 have frequently included patients only from clinical trial populations or those not taking evidence-based medications, or have been restricted to high-risk subgroups of individuals, such as those with diabetes.14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27 Therefore, we examine the risk for, and risk factors associated with, recurrent MI and CHD events and the mortality rate among a broader group of US adults who were intensively medically managed after hospital discharge for MI. Better quantification of the magnitude of the residual risk in this population will help inform clinicians as they determine which subgroups of patients might benefit most from additional risk reduction measures after MI.
Section snippets
Methods
We conducted a retrospective cohort study among US adults in the MarketScan and Medicare databases who had an MI between January 1, 2014 and June 30, 2015 and among three comparison groups. The MarketScan database contains data for individuals in the US with commercial and Medicare supplemental health insurance and was obtained from Truven Health Analytics. Medicare is a US federal program that provides health insurance for adults aged ≥65 years and adults <65 years with end-stage renal disease
Results
A total of 16,853 of 72,116 (23%) beneficiaries meeting the eligibility criteria were intensively medically managed after MI (eFig. 1). Their characteristics and those of the three comparison populations are shown in Table 1. Beneficiaries who were intensively medically managed after MI were more likely to have diabetes and heart failure and less likely to have a history of stroke when compared with their counterparts in the overall population. They were more likely to be white and have a
Discussion
Beneficiaries in the present study who were intensively medically managed after MI had high rates for recurrent MI and CHD events (33–72 events per 1000 person-years). These event rates were much higher than those observed in a group of matched beneficiaries in the general MarketScan and Medicare population and those with diabetes or a history of CHD. The increased risk persisted even when the analysis was restricted to beneficiaries with high adherence to all four classes of medications for
Conclusions
Despite intensive medical management with a high-intensity statin, beta-blocker, an ACE inhibitor or ARB, and prescription antiplatelet agent, patients with MI have a high risk for recurrent MI and CHD events and a higher risk for all-cause mortality as compared with the general population. Interventions to reduce this residual risk are warranted.
Acknowledgments
The design and conduct of the study, analysis and interpretation of the data, and preparation of the manuscript were supported through a research grant from Amgen, Inc. (Thousand Oaks, CA). K.L.M. and R.M.S. are employees of Amgen, Inc. The academic authors conducted all analyses and maintain the rights to publish this article. R.S.R. receives research support from Akcea, Amgen, The Medicines Company, and Regeneron; serves on Advisory Boards for Akcea, Amgen, Inc., the Medicines Company, and
References (33)
- et al.
2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2014) - et al.
2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines
J Am Coll Cardiol
(2013) - et al.
2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
J Am Coll Cardiol
(2012) - et al.
National Lipid Association Scientific Statement on the use of icosapent ethyl in statin-treated patients with elevated triglycerides and high or very-high ASCVD risk
J Clin Lipidol
(2019) - et al.
Enhancing the value of PCSK9 monoclonal antibodies by identifying patients most likely to benefit
J Clin Lipidol
(2019) - et al.
Determining when to add nonstatin therapy: a quantitative approach
J Am Coll Cardiol
(2016) - et al.
Preexisting cardiovascular conditions and long-term prognosis after initial myocardial infarction: The Framingham Study
Am Heart J
(1993) - et al.
Risk and timing of recurrent ischemic events among patients with stable ischemic heart disease, non-ST-segment elevation acute coronary syndrome, and ST-segment elevation myocardial infarction
Am Heart J
(2016) - et al.
Trends in acute myocardial infarction event rates and risk of recurrences after an incident event in Norway 1994 to 2009 (from a cardiovascular disease in Norway project)
Am J Cardiol
(2014) - et al.
Heart disease and stroke statistics—2019 update: a report from the American Heart Association
Circulation
(2019)