Garg Pallav, Wijeysundera Harindra C, Yun Lingsong, Cantor Warren J, Ko Dennis T
Department of Medicine, London Health Sciences Center, Western University, London, ON, Canada (P.G.).
Institute for Clinical Evaluative Sciences, Toronto, ON, Canada (H.C.W., L.Y., D.T.K.) Sunnybrook Health Sciences Center, Toronto, ON, Canada (H.C.W., D.T.K.) Department of Medicine, University of Toronto, Toronto, ON, Canada (H.C.W., W.J.C., D.T.K.).
J Am Heart Assoc. 2014 Aug 13;3(4):e000882. doi: 10.1161/JAHA.114.000882.
Clinical guidelines emphasize medical therapy as the initial approach to the management of patients with stable coronary artery disease (CAD). However, the extent to which medical therapy is applied before and after percutaneous coronary intervention (PCI) in contemporary clinical practice is uncertain. We evaluated medication use for patients with stable CAD undergoing PCI, and assessed whether the COURAGE study altered medication use in the Canadian healthcare system.
A population-based cohort of 23 680 older patients >65 years old) with stable CAD undergoing PCI in Ontario between 2003 and 2010 was assembled. Optimal medical therapy (OMT) was defined as prescription for a β-blocker, statin, and either angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker in the 90 days before PCI, and the same medications plus thienopyridine 90 days following PCI. Prior to PCI, 8023 (33.9%) patients were receiving OMT, 11 891 (50.2%) were on suboptimal therapy, and 3766 (15.9%) were not prescribed any medications of interest. There was significant improvement in medical therapy following PCI (OMT: 11 149 [47.1%], suboptimal therapy: 11 591 [48.9%], and none: 940 [4.0%], P<0.001). Utilization rate of OMT reduced significantly after the publication of COURAGE (34.9% before versus 32.8% after, P<0.001). Similarly, the rate of OMT following PCI was lower in the period after publication of COURAGE (47.3% before versus 46.9% after, P<0.001).
OMT was prescribed in about 1 in 3 patients prior to PCI and less than half after PCI. In contrast to the anticipated impact of COURAGE, we found lower rates of medication use in PCI patients after its publication.
临床指南强调药物治疗是稳定型冠状动脉疾病（CAD）患者管理的初始方法。然而，在当代临床实践中，经皮冠状动脉介入治疗（PCI）前后药物治疗的应用程度尚不确定。我们评估了接受PCI的稳定型CAD患者的用药情况，并评估了COURAGE研究是否改变了加拿大医疗系统中的用药情况。
收集了2003年至2010年间安大略省23680名年龄>65岁的接受PCI的稳定型CAD老年患者的基于人群的队列。最佳药物治疗（OMT）定义为PCI前90天使用β受体阻滞剂、他汀类药物以及血管紧张素转换酶抑制剂或血管紧张素II受体阻滞剂的处方，PCI后90天使用相同药物加噻吩并吡啶。PCI前，8023名（33.9%）患者接受OMT，11891名（50.2%）接受次优治疗，3766名（15.9%）未开具任何相关药物。PCI后药物治疗有显著改善（OMT：11149名[47.1%]，次优治疗：11591名[48.9%]，无治疗：940名[4.0%]，P<0.001）。COURAGE研究发表后，OMT的使用率显著降低（发表前为34.9%，发表后为32.8%，P<0.001）。同样，COURAGE研究发表后的时期内，PCI后OMT的使用率也较低（发表前为47.3%，发表后为46.9%，P<0.001）。
约三分之一的患者在PCI前接受OMT，PCI后不到一半。与COURAGE研究预期的影响相反，我们发现该研究发表后PCI患者的用药率较低。
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