The role of in-hospital initiation of cardiovascular protective therapies to improve treatment rates and clinical outcomes.

Patients with acute myocardial infarction (MI) face a high risk of recurrent cardiovascular events, repeat hospitalizations, heart failure, and mortality. There is compelling scientific evidence that antiplatelet therapy, beta-blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering therapy reduce these risks in patients with acute MI. Despite this evidence and national guidelines, a number of studies in a variety of clinical settings have documented that a significant proportion of patients with acute MI is not being treated with these guideline-recommended, evidence-based therapies when receiving conventional care. The demonstration that initiation of cardiovascular protective medications, including lipid-lowering therapy, prior to hospital discharge for atherosclerotic cardiovascular events results in a marked increase in treatment rates, improved long-term patient compliance, and better clinical outcomes has led to the revision of national guidelines to endorse this approach as the standard of care. Physicians have been reluctant to initiate beta-blockers in post-MI patients with significant left ventricular dysfunction and/or heart failure symptoms, and this reluctance has contributed to the treatment gap. Recent studies suggest that when the beta-blocker carvedilol is initiated in acute-MI patients with left ventricular dysfunction with or without symptoms of heart failure prior to hospital discharge, it is safe and effective and improves clinical outcomes. Adopting in-hospital initiation of cardiovascular protective medications as the standard of care for patients hospitalized with acute MI could dramatically improve treatment rates and thus substantially reduce the risk of future cardiovascular events and hospitalizations and prolong life in the large number of patients hospitalized each year.