Division of Vascular Surgery, University of Vermont Medical Center, Burlington, Vt.
University of Vermont College of Medicine, Burlington, Vt.
J Vasc Surg. 2018 Jan;67(1):279-286.e2. doi: 10.1016/j.jvs.2017.06.093. Epub 2017 Aug 19.
The objective of this study was to investigate adherence to practice guidelines for antiplatelet and statin use after postoperative myocardial infarction (POMI) and its effect on late mortality following vascular surgery in a multicenter registry.
Antiplatelet and statin use was examined in 1749 vascular surgery procedures with POMI within the Vascular Quality Initiative (VQI) from 2005 to 2015. Our primary aim was to assess cardiac medication (CM) use at discharge, defined as (1) single antiplatelet therapy (SAPT; aspirin or P2Y inhibitor) or dual antiplatelet therapy (DAPT; aspirin and P2Y inhibitor) and (2) statin therapy. Long-term mortality in patients with POMI was analyzed on the basis of discharge CM. A proportional hazards model was developed to control for factors associated with mortality. Regional differences in CM use at discharge after POMI were compared.
Overall discharge CM use after POMI included aspirin (81%), P2Y inhibitor (38%), statin therapy (76%), and combined antiplatelet and statin (74%). At discharge, 26% of patients were not receiving combined antiplatelet and statin therapy. SAPT (50%) was more common than DAPT (35%; P < .001). Patients with POMI undergoing carotid endarterectomy were more likely to be discharged on CM (80%) compared with patients undergoing infrainguinal bypass (78%), suprainguinal bypass (72%), endovascular aneurysm repair (71%), and open abdominal aortic aneurysm repair (59%; P < .001). Patients receiving SAPT or DAPT plus statin therapy had improved survival (79%) compared with those receiving noncombination or no therapy (69%) with mean follow-up of 5.5 years and 4.9 years, respectively (log-rank, P = .001). After adjustment for covariates including preoperative medications, treatment with SAPT or DAPT plus statin at discharge was associated with lower late mortality compared with noncombination or no therapy (hazard ratio, 0.72; 95% confidence interval, 0.56-0.93; P = .01). Regional variation in CM at discharge following POMI was also observed with a range of 33% to 100% (P = .05).
Within the VQI, regional and procedure-specific variation exists in CM regimen after POMI following vascular surgery. Absence of combined antiplatelet and statin therapy at discharge after POMI was associated with higher late mortality and represents an area for quality improvement in the care of these patients.
本研究旨在调查术后心肌梗死（POMI）后抗血小板和他汀类药物使用的实践指南依从性及其对血管手术后晚期死亡率的影响，研究对象为多中心注册登记处的 1749 例血管手术。
2005 年至 2015 年，血管质量倡议（VQI）中纳入了 1749 例 POMI 血管手术，对其抗血小板和他汀类药物使用情况进行了研究。我们的主要目的是评估出院时的心脏药物（CM）使用情况，定义为（1）单一抗血小板治疗（SAPT；阿司匹林或 P2Y 抑制剂）或双联抗血小板治疗（DAPT；阿司匹林和 P2Y 抑制剂）和（2）他汀类药物治疗。根据 POMI 后的出院 CM，分析患者的长期死亡率。采用比例风险模型控制与死亡率相关的因素。比较 POMI 后出院时 CM 使用的区域差异。
总体而言，POMI 后出院时的 CM 使用率包括阿司匹林（81%）、P2Y 抑制剂（38%）、他汀类药物治疗（76%）和联合抗血小板和他汀类药物（74%）。出院时，有 26%的患者未接受联合抗血小板和他汀类药物治疗。SAPT（50%）比 DAPT（35%；P<0.001）更为常见。与行下肢旁路手术（78%）、上肢旁路手术（72%）、血管内动脉瘤修复术（71%）和开放性腹主动脉瘤修复术（59%）相比，行颈动脉内膜切除术的 POMI 患者更有可能接受 CM 治疗（80%）（P<0.001）。接受 SAPT 或 DAPT 加他汀类药物治疗的患者与接受非联合或无治疗的患者相比，生存状况得到改善（分别为 79%和 69%），平均随访时间分别为 5.5 年和 4.9 年（对数秩检验，P=0.001）。在校正包括术前用药在内的混杂因素后，与非联合或无治疗相比，出院时接受 SAPT 或 DAPT 加他汀类药物治疗与较低的晚期死亡率相关（风险比，0.72；95%置信区间，0.56-0.93；P=0.01）。在 POMI 后出院时，CM 的使用情况也存在区域差异，范围为 33%至 100%（P=0.05）。
在 VQI 中，血管手术后 POMI 后 CM 方案的使用存在区域和手术特异性差异。POMI 后出院时未联合使用抗血小板和他汀类药物与晚期死亡率较高相关，是改善此类患者治疗质量的一个领域。
