Zullo Andrew R, Mogul Amanda, Corsi Katherine, Shah Nishant R, Lee Sei J, Rudolph James L, Wu Wen-Chih, Dapaah-Afriyie Ruth, Berard-Collins Christine, Steinman Michael A
Department of Health Services, Policy, and Practice (A.R.Z., N.R.S., J.L.R., W.- C.W.), Brown University School of Public Health, Providence, RI.
Department of Epidemiology (A.R.Z., W.-C.W.), Brown University School of Public Health, Providence, RI.
Circ Cardiovasc Qual Outcomes. 2019 Apr;12(4):e004942. doi: 10.1161/CIRCOUTCOMES.118.004942.
Background Secondary prevention medications are often not prescribed to frail, older adults following acute myocardial infarction, potentially because of the absence of data to support use, perceived lack of benefit, and concern over possible harms. We examined the effect of using more guideline-recommended medications after myocardial infarction on mortality, rehospitalization, and functional decline in the frailest and oldest segment of the US population-long-stay nursing home residents. Methods and Results We conducted a retrospective cohort study of nursing home residents aged ≥65 years using 2007 to 2010 national US Minimum Data Set clinical assessment data and Medicare claims. Exposure was the number of secondary prevention medications (antiplatelets, β-blockers, statins, and renin-angiotensin-aldosterone system inhibitors) initiated after myocardial infarction. Outcomes were 90-day death, rehospitalization, and functional decline. We compared outcomes for new users of 2 versus 1 and 3 or 4 versus 1 medications using the inverse probability of treatment-weighted odds ratios with 95% CI. The cohort comprised 4787 residents, with a total of 509 death, 820 functional decline, and 1226 rehospitalization events. Compared with individuals who initiated 1 medication, mortality odds ratios were 0.98 (95% CI, 0.79-1.22) and 0.74 (95% CI, 0.57-0.97) for users of 2 and 3 or 4 medications, respectively. Rehospitalization odds ratios were 1.00 (95% CI, 0.85-1.17) for 2 and 0.97 (95% CI, 0.8-1.17) for 3 or 4 medications. Functional decline odds ratios were 1.04 (95% CI, 0.85-1.28) for 2 and 1.12 (95% CI, 0.89-1.40) for 3 or 4 medications. In a stability analysis excluding antiplatelet drugs from the exposure definition, more medication use was associated with functional decline. Conclusions Use of more guideline-recommended medications after myocardial infarction was associated with decreased mortality in older, predominantly frail adults, but no difference in rehospitalization. Results for functional decline from the main and stability analyses were discordant and did not rule out an increased risk associated with more medication use.
急性心肌梗死后，针对体弱的老年人，二级预防药物往往未被处方，这可能是因为缺乏支持用药的数据、认为无益处以及担心可能的危害。我们研究了心肌梗死后使用更多指南推荐药物对美国最体弱和最年长人群（长期护理院居民）的死亡率、再住院率和功能衰退的影响。
我们利用2007年至2010年美国国家最低数据集临床评估数据和医疗保险理赔记录，对年龄≥65岁的护理院居民进行了一项回顾性队列研究。暴露因素是心肌梗死后开始使用的二级预防药物（抗血小板药物、β受体阻滞剂、他汀类药物和肾素 - 血管紧张素 - 醛固酮系统抑制剂）的数量。结局指标为90天死亡率、再住院率和功能衰退。我们使用治疗加权逆概率比值比及95%置信区间，比较了使用2种药物与1种药物、3或4种药物与1种药物的新使用者的结局。该队列包括4787名居民，共有509例死亡、820例功能衰退和1226例再住院事件。与开始使用1种药物的个体相比，使用2种药物和3或4种药物的使用者的死亡比值比分别为0.98（95%置信区间，0.79 - 1.22）和0.74（95%置信区间，0.57 - 0.97）。使用2种药物和3或4种药物的再住院比值比分别为1.00（95%置信区间，0.85 - 1.17）和0.97（95%置信区间，0.8 - 1.17）。使用2种药物和3或4种药物的功能衰退比值比分别为1.04（95%置信区间，0.85 - 1.28）和1.12（95%置信区间，0.89 - 1.40）。在一项稳定性分析中，将抗血小板药物排除在暴露定义之外，更多药物使用与功能衰退相关。
心肌梗死后使用更多指南推荐药物与老年（主要是体弱）成年人死亡率降低相关，但再住院率无差异。主要分析和稳定性分析中功能衰退的结果不一致，且未排除更多药物使用相关的风险增加。
