Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
J Am Coll Cardiol. 2013 Nov 5;62(19):1791-801. doi: 10.1016/j.jacc.2013.04.102. Epub 2013 Aug 21.
The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI).
Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown.
We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥ 75% target). Patients with contraindications were excluded from analyses for that medication.
Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each.
Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.
本研究旨在考察急性心肌梗死（AMI）的绩效评估指标所量化的药物处方模式。
目前的 AMI 绩效评估指标旨在通过量化基于证据的治疗方法的使用来提高治疗质量。然而，这些指标仅评估药物处方。患者在 AMI 后出院时和出院后是否接受最佳的二级预防药物剂量尚不清楚。
我们评估了 31 家医院的 6748 名患者在 2 个美国注册中心（2003 年至 2008 年）的出院时和 AMI 后 12 个月时的β受体阻滞剂、他汀类药物和血管紧张素转换酶抑制剂（ACEI）/血管紧张素 II 受体阻滞剂（ARB）的治疗剂量。处方剂量分为无剂量、低剂量（低于来自重要临床试验的目标剂量的 50%）、中剂量（50%至 74%目标剂量）和高剂量（≥75%目标剂量）。有禁忌症的患者被排除在该药物的分析之外。
大多数符合条件的患者（>87%）在出院时开了某种剂量的每种药物，但只有 1/3 的患者开了目标剂量的药物。在未开高剂量药物的患者中，随访期间药物剂量调整的情况并不常见（每种药物约 25%的患者）。在 12 个月时，β受体阻滞剂、他汀类药物和 ACEI/ARB 的高剂量目标仅分别在 12%、26%和 32%的合格患者中达到。多变量调整后，出院时开高剂量药物与随访时达到高剂量药物之间存在强烈关联：β受体阻滞剂，调整后的比值比（OR）：6.08（95%置信区间[CI]：3.70 至 10.01）；他汀类药物，调整后的 OR：8.22（95%CI：6.20 至 10.90）；ACEI/ARB，调整后的 OR：5.80（95%CI：2.56 至 13.16）；p<0.001 各药物）。
尽管几乎所有 AMI 后出院的患者都接受了适当的二级预防药物治疗，但剂量增加的情况并不常见，大多数患者的药物剂量低于临床试验中具有明确疗效的剂量。将剂量强度纳入绩效评估指标可能有助于改善 AMI 后的最佳药物治疗。
