Better Adherence to Guideline Advice Pays Off After Acute MI

Full adherence to guideline-recommended medical therapy, risk factor control, and lifestyle changes following an acute MI is associated with the greatest survival benefit, according to results of a community-based population study.

“One thing that this I think really highlighted for us was how important systems-based approaches to getting patients educated about their heart health and making sure they're meeting all the guideline recommendations is,” lead author Matthew Solomon, MD, PhD (Kaiser Permanente Northern California, Oakland), told TCTMD, adding that at his institution specifically, this is primarily done through a home-based cardiac rehabilitation program with about a 70% participation rate. “This is really a big win for cardiac rehab and should encourage the national medical societies, as well, and just the field in general to further promote that for our patients.”

Digging Into the Recommendations

For the study, published online last week ahead of print in the Journal of the American Heart Association, Solomon and colleagues looked at more than 25,000 adults with acute MI who were discharged from their Northern California healthcare system between 2008 and 2014. They considered adherence to the following seven secondary prevention guideline recommendations:

• Filled prescription for an ACE inhibitor or angiotensin receptor blocker (ARB)
• Filled prescription for a beta-blocker
• Filled prescription of an antiplatelet agent (P2Y12 inhibitors)
• Filled prescription of a lipid-lowering agent (statin and non-statin agents)
• Outpatient blood pressure < 140/90 mm Hg
• Not smoking tobacco after discharge

Achieving LDL cholesterol < 100 mg/dL (among those surviving to 90 days postdischarge)

Just over one-third of patients adhered to five or six guidelines at 30 days, while 31% and 23% adhered to six or seven guidelines, respectively, at 90 days. Over a median follow-up period of 2.8 years, adherence to more guidelines was independently associated with lower mortality.

Mortality Risk by Guideline Adherence

The findings were similar across patient subgroups classified by age, sex, diabetes, and chronic kidney disease.

Looking at each individual guideline recommendation, patient adherence to antiplatelet agents and lipid-lowering medications was independently associated with lower mortality in both the 30- and 90-day models. On the other hand, achieving the blood pressure threshold, not smoking, and receiving an ACE inhibitor or ARB were not. Beta-blocker prescription (at least in the 30-day model) and achievement of an LDL-cholesterol level < 100 mg/dL at 90 days were both linked with lower mortality.

All Better Than Most

Solomon said he was surprised not to see “diminishing returns” on the effects of guideline adherence over time. “We thought okay, patients who achieved six out of seven of these are probably going to maybe do just the same as patients who achieved seven out of seven,” he said. “But we saw a pretty substantial difference in the long-term survival for patients that were able to achieve all seven versus all six. . . . It really seemed to matter a lot to be fully adherent.”

Commenting for TCTMD, Michael Blaha, MD (Johns Hopkins Hospital, Baltimore, MD), said in an email that the implications “are more at the implementation science and healthcare system level. The study appears to support the importance of all current guidelines, and points to the need for health system-wide strategies to increase broad adherence to our established guidelines.”

But the best way to accomplish this is still unknown, he added. “We are in desperate need [of] strategies to increase adherence to our proven clinical guidelines. Wearables, mobile health apps and tools, and tele-rehab are all intriguing strategies to increase guideline adherence.”

Doctors and patients really need to work to ensure that every single evidence-based recommendation is followed. Following most of the recommended treatments isn't enough. Matthew Solomon

Next, Solomon said, he would like to see future studies seek to understand the importance of post-MI risk factors beyond the traditional ones. “What are other ways we can help improve patient outcomes in the long term?” he asked. “Further, within each of the already known and recommended guidelines, there's always controversy about what's the right number. For example, for cholesterol, how low should we go? Which therapies are indicated for which patients? And so I think refinement in our ability to tailor therapies and medicines to patients in a more personalized fashion will really be the future.”

Also, it will be important for researchers to better understand the barriers for patients being able to achieve all of the guideline-recommended therapies, “so that we can think about interventions to overcome those barriers,” Solomon added.

“People can often think that they're fixed after they're treated for a heart attack, especially if they . . . get an amazing procedure from our interventional cardiologists,” he concluded. “They think: ‘All is said and done. My chest pain went away, and I feel fine now.’ But our findings show that you really need to follow all of the recommended treatments after a heart attack and that's critical to long-term health and wellness. So, doctors and patients really need to work to ensure that every single evidence-based recommendation is followed. Following most of the recommended treatments isn't enough.”