Division of Research Kaiser Permanente Northern California Oakland CA.
Division of Cardiology Kaiser Permanente Oakland Medical Center Oakland CA.
J Am Heart Assoc. 2020 Mar 17;9(6):e014415. doi: 10.1161/JAHA.119.014415. Epub 2020 Mar 5.
Background The survival benefit associated with cumulative adherence to multiple clinical and lifestyle-related guideline recommendations for secondary prevention after acute myocardial infarction (AMI) is not well established. Methods and Results We examined adults with AMI (mean age 68 years; 64% men) surviving at least 30 (N=25 778) or 90 (N=24 200) days after discharge in a large integrated healthcare system in Northern California from 2008 to 2014. The association between all-cause death and adherence to 6 or 7 secondary prevention guideline recommendations including medical treatment (prescriptions for β-blockers, renin-angiotensin-aldosterone system inhibitors, lipid medications, and antiplatelet medications), risk factor control (blood pressure <140/90 mm Hg and low-density lipoprotein cholesterol <100 mg/dL), and lifestyle approaches (not smoking) at 30 or 90 days after AMI was evaluated with Cox proportional hazard models. To allow patients time to achieve low-density lipoprotein cholesterol <100 mg/dL, this metric was examined only among those alive 90 days after AMI. Overall guideline adherence was high (35% and 34% met 5 or 6 guidelines at 30 days; and 31% and 23% met 6 or 7 at 90 days, respectively). Greater guideline adherence was independently associated with lower mortality (hazard ratio, 0.57 [95% CI, 0.49-0.66] for those meeting 7 and hazard ratio, 0.69 [95% CI, 0.61-0.78] for those meeting 6 guidelines versus 0 to 3 guidelines in 90-day models, with similar results in the 30-day models), with significantly lower mortality per each additional guideline recommendation achieved. Conclusions In a large community-based population, cumulative adherence to guideline-recommended medical therapy, risk factor control, and lifestyle changes after AMI was associated with improved long-term survival. Full adherence was associated with the greatest survival benefit.
急性心肌梗死（AMI）后，累积坚持多项临床和生活方式相关的二级预防指南建议对生存获益的影响尚未明确。
我们在加利福尼亚州北部的一个大型综合医疗系统中，研究了至少在出院后 30（N=25778）或 90（N=24200）天存活的 AMI 成年人（平均年龄 68 岁；64%为男性）。采用 Cox 比例风险模型评估 AMI 后 30 或 90 天所有原因死亡与以下 6 或 7 项二级预防指南建议（包括药物治疗[β受体阻滞剂、肾素-血管紧张素-醛固酮系统抑制剂、调脂药物和抗血小板药物]、危险因素控制（血压<140/90mmHg 和低密度脂蛋白胆固醇<100mg/dL）和生活方式方法（不吸烟））的关联性。为了让患者有时间达到低密度脂蛋白胆固醇<100mg/dL，仅在 AMI 后 90 天存活的患者中检查了这一指标。总体指南坚持率较高（30 天时分别有 35%和 34%的患者符合 5 或 6 项指南；90 天时分别有 31%和 23%的患者符合 6 或 7 项指南）。更高的指南坚持率与死亡率降低独立相关（90 天模型中，符合 7 项指南的患者死亡风险比为 0.57（95%CI，0.49-0.66），符合 6 项指南的患者死亡风险比为 0.69（95%CI，0.61-0.78），而 0-3 项指南的患者为 1，90 天模型中也得到了类似的结果，每增加一项符合的指南建议，死亡率就会显著降低）。
在一个大型社区人群中，累积坚持 AMI 后指南推荐的药物治疗、危险因素控制和生活方式改变与长期生存改善相关。完全坚持与最大的生存获益相关。
