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Disparity in the Application of Guideline-Based Medical Therapy after Percutaneous Coronary Intervention: Analysis from the Japanese Prospective Multicenter Registry

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Abstract

Background

Despite the known benefits of evidence-based medical care in patients with coronary artery disease, disparities exist in the application of guideline-based medical therapy (GBMT) after percutaneous coronary intervention (PCI), particularly in patients who have undergone revascularization procedures. Underestimation of risk, overestimation of side effects, and preference of the treating physician to prioritize invasive procedures may all affect the prescription pattern.

Objective

We sought to describe how GBMT is prescribed after PCI in Japan.

Methods

From September 2008 to 2010, 1,612 patients underwent PCI with stenting at 14 Japanese hospitals participating in the Japanese Cardiovascular Database Registry. GBMT was defined as treatment including dual antiplatelet therapy, beta-adrenoceptor antagonists (beta-blockers) and/or calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, and statins.

Results

Overall, 749 patients (46.5 %) were discharged on GBMT. Notably, the prescription rate of GBMT became lower with age (e.g. from 50.3 % [age 50–59 years] to 35.9 % [age over 80 years]). In addition, patients presenting with acute coronary syndrome (ACS) tended to receive GBMT more frequently (ST-segment elevation myocardial infarction [STEMI] 33.8 vs. 18.3 %; p < 0.001; non-ST-segment elevation myocardial infarction [NSTEMI] 8.5 vs. 5.9 %; p = 0.042), whereas patients presenting with cardiogenic shock (CS) had lower prescription rates of GBMT (2.1 vs. 4.1 %; p = 0.032). Overall age (odds ratio [OR] 0.647; p = 0.020), as well as the acute and emergent presentation (OR 3.229; p < 0.001 for STEMI; OR 2.122; p < 0.001 for NSTEMI; OR 0.35; p = 0.002 for CS) were also associated with prescription of GBMT.

Conclusion

Only about half of the post-PCI patients were discharged on ideal GBMT. Elderly patients and those presenting with non-ACS status or hemodynamic compromise tended not to receive GBMT, and required more attention for optimization of their care.

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References

  1. Grundy SM, Cleeman JI, Merz CN, et al. Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines. J Am Coll Cardiol. 2004;44(3):720–32.

    Article  PubMed  Google Scholar 

  2. Smith SC Jr, Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol. 2006;47(10):2130–9.

    Article  PubMed  Google Scholar 

  3. Ozasa N, Kimura T, Morimoto T, et al. Lack of effect of oral beta-blocker therapy at discharge on long-term clinical outcomes of ST-segment elevation acute myocardial infarction after primary percutaneous coronary intervention. Am J Cardiol. 2010;106(9):1225–33.

    Article  PubMed  CAS  Google Scholar 

  4. Kimura T, Morimoto T, Furukawa Y, et al. Long-term outcomes of coronary-artery bypass graft surgery versus percutaneous coronary intervention for multivessel coronary artery disease in the bare-metal stent era. Circulation. 2008;118(14 Suppl):S199–209.

    Article  PubMed  Google Scholar 

  5. Nishigaki K, Yamazaki T, Kitabatake A, et al. Percutaneous coronary intervention plus medical therapy reduces the incidence of acute coronary syndrome more effectively than initial medical therapy only among patients with low-risk coronary artery disease: a randomized, comparative, multicenter study. JACC Cardiovasc Interv. 2008;1(5):469–79.

    Article  PubMed  Google Scholar 

  6. Roe MT, Messenger JC, Weintraub WS, et al. Treatments, trends, and outcomes of acute myocardial infarction and percutaneous coronary intervention. J Am Coll Cardiol. 2010;56(4):254–63.

    Article  PubMed  Google Scholar 

  7. Yasue H, Omote S, Takizawa A, et al. Coronary arterial spasm in ischemic heart disease and its pathogenesis: a review. Circ Res. 1983;52(2 Pt 2):I147–52.

    PubMed  CAS  Google Scholar 

  8. Antman EM, Hand M, Armstrong PW, et al. 2007 focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;51(2):210–47.

    Article  PubMed  Google Scholar 

  9. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons, endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. J Am Coll Cardiol. 2007;50(7):e1–157.

    Article  PubMed  Google Scholar 

  10. Fraker TD Jr, Fihn SD, Gibbons RJ, et al. 2007 chronic angina focused update of the ACC/AHA 2002 guidelines for the management of patients with chronic stable angina: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Writing Group to develop the focused update of the 2002 guidelines for the management of patients with chronic stable angina. J Am Coll Cardiol. 2007;50(23):2264–74.

    Article  PubMed  Google Scholar 

  11. Ogawa H, Akasaka T, Hattori R, et al. Guidelines for diagnosis and treatment of patients with vasospastic angina (coronary spastic angina) (JCS 2008): digest version. Circ J. 2010;74(8):1745–62.

    Article  Google Scholar 

  12. Ueshima H, Okayama A, Saitoh S, et al. Differences in cardiovascular disease risk factors between Japanese in Japan and Japanese-Americans in Hawaii: the INTERLIPID study. J Hum Hypertens. 2003;17(9):631–9.

    Article  PubMed  CAS  Google Scholar 

  13. Curb JD, Ueshima H, Rodriguez BL, et al. Differences in lipoprotein particle subclass distribution for Japanese Americans in Hawaii and Japanese in Japan: the INTERLIPID study. J Clin Lipidol. 2011;5(1):30–6.

    Article  PubMed  Google Scholar 

  14. Roberts R, Rogers WJ, Mueller HS, et al. Immediate versus deferred beta-blockade following thrombolytic therapy in patients with acute myocardial infarction: results of the Thrombolysis in Myocardial Infarction (TIMI) II-B Study. Circulation. 1991;83(2):422–37.

    Article  PubMed  CAS  Google Scholar 

  15. Metoprolol in acute myocardial infarction (MIAMI). A randomised placebo-controlled international trial. The MIAMI Trial Research Group. Eur Heart J. 1985;6(3):199–226.

    Google Scholar 

  16. Randomised trial of intravenous atenolol among 16 027 cases of suspected acute myocardial infarction: ISIS-1. First International Study of Infarct Survival Collaborative Group. Lancet. 1986;2(8498):57–66.

  17. Pristipino C, Beltrame JF, Finocchiaro ML, et al. Major racial differences in coronary constrictor response between Japanese and Caucasians with recent myocardial infarction. Circulation. 2000;101(10):1102–8.

    Article  PubMed  CAS  Google Scholar 

  18. Maron DJ, Spertus JA, Mancini GB, et al. Impact of an initial strategy of medical therapy without percutaneous coronary intervention in high-risk patients from the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial. Am J Cardiol. 2009;104(8):1055–62.

    Article  PubMed  Google Scholar 

  19. Kandzari DE, Roe MT, Chen AY, et al. Influence of clinical trial enrollment on the quality of care and outcomes for patients with non-ST-segment elevation acute coronary syndromes. Am Heart J. 2005;149(3):474–81.

    Article  PubMed  Google Scholar 

  20. Boden WE, O’Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–16.

    Article  PubMed  CAS  Google Scholar 

  21. Spertus JA, Kettelkamp R, Vance C, et al. Prevalence, predictors, and outcomes of premature discontinuation of thienopyridine therapy after drug-eluting stent placement: results from the PREMIER registry. Circulation. 2006;113(24):2803–9.

    Article  PubMed  CAS  Google Scholar 

  22. Maddox TM, Ho PM, Roe M, et al. Utilization of secondary prevention therapies in patients with nonobstructive coronary artery disease identified during cardiac catheterization: insights from the National Cardiovascular Data Registry Cath-PCI Registry. Circ Cardiovasc Qual Outcomes. 2010;3(6):632–41.

    Article  PubMed  Google Scholar 

  23. Hutchinson-Jaffe AB, Goodman SG, Yan RT, et al. Comparison of baseline characteristics, management and outcome of patients with non-ST-segment elevation acute coronary syndrome in versus not in clinical trials. Am J Cardiol. 2010;106(10):1389–96.

    Article  PubMed  Google Scholar 

  24. Yan AT, Tan M, Fitchett D, et al. One-year outcome of patients after acute coronary syndromes (from the Canadian Acute Coronary Syndromes Registry). Am J Cardiol. 2004;94(1):25–9.

    Article  PubMed  Google Scholar 

  25. Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961–72.

    Article  PubMed  CAS  Google Scholar 

  26. Steg PG, Fox KA, Eagle KA, et al. Mortality following placement of drug-eluting and bare-metal stents for ST-segment elevation acute myocardial infarction in the Global Registry of Acute Coronary Events. Eur Heart J. 2009;30(3):321–9.

    Article  PubMed  Google Scholar 

  27. Stone GW, Maehara A, Lansky AJ, et al. A prospective natural-history study of coronary atherosclerosis. N Engl J Med. 2011;364(3):226–35.

    Article  PubMed  CAS  Google Scholar 

  28. Bhatt DL, Steg PG, Ohman EM, et al. International prevalence, recognition, and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA. 2006;295(2):180–9.

    Article  PubMed  CAS  Google Scholar 

  29. Steinberg BA, Steg PG, Bhatt DL, et al. Comparisons of guideline-recommended therapies in patients with documented coronary artery disease having percutaneous coronary intervention versus coronary artery bypass grafting versus medical therapy only (from the REACH International Registry). Am J Cardiol. 2007;99(9):1212–5.

    Article  PubMed  Google Scholar 

  30. Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization and long-term survival in cardiogenic shock complicating acute myocardial infarction. JAMA. 2006;295(21):2511–5.

    Article  PubMed  Google Scholar 

  31. Olomu AB, Grzybowski M, Ramanath VS, et al. Evidence of disparity in the application of quality improvement efforts for the treatment of acute myocardial infarction: the American College of Cardiology’s Guidelines applied in practice initiative in Michigan. Am Heart J. 2010;159(3):377–84.

    Article  PubMed  Google Scholar 

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Acknowledgments

The authors appreciate all the investigators, clinical coordinators, and institutions involved in the JCD study.

Funding

This study was funded by SENSHIN Medical Research Foundation and Pfeizer Health Research Foundation.

Author information

Authors and Affiliations

  1. Department of Cardiology, Keio University School of Medicine, Tokyo, Japan

    Ayaka Endo, Shun Kohsaka, Akio Kawamura & Keiichi Fukuda

  2. University of Tokyo, Healthcare Quality Assessment, Tokyo, Japan

    Hiroaki Miyata

  3. Department of Cardiology, Saiseikai Utsunomiya Hospital, Tochigi, Japan

    Shigetaka Noma

  4. Department of Cardiology, National Hospital Organization, Saitama National Hospital, Saitama, Japan

    Masahiro Suzuki

  5. Department of Cardiology, Tachikawa Hospital, Tokyo, Japan

    Takashi Koyama

  6. Department of Cardiology, Saitama City Hospital, Saitama, Japan

    Shiro Ishikawa

  7. Department of Cardiology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan

    Yukihiko Momiyama

  8. Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan

    Susumu Nakagawa

  9. Department of Cardiology, Kawasaki City Municipal Hospital, Kawasaki, Kanagawa, Japan

    Koichiro Sueyoshi

  10. Department of Cardiology, Hiratsuka Municipal Hospital, Hiratsuka, Kanagawa, Japan

    Shunsuke Takagi

  11. Department of Cardiology, Ashikaga Red Cross Hospital, Ashikaga, Tochigi, Japan

    Toshiyuki Takahashi

  12. Center for Clinical Research, Keio University School of Medicine, Tokyo, Japan

    Yuji Sato

  13. Department of Cardiology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan

    Satoshi Ogawa

  14. Division of Cardiology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan

    Ayaka Endo

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  1. Ayaka Endo
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Corresponding author

Correspondence to Ayaka Endo.

Additional information

For the JCD-KICS Investigators. The Investigators are listed in Appendix.

Electronic supplementary material

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Supplementary material 1 (PDF 125 kb)

Appendix

Appendix

Investigators: Yohei Numasawa, Toshiki Kuno, Toshiyuki Takahashi (Ashikaga Red Cross Hospital), Yutaka Okada (Eiju General Hospital), Soushin Inoue, Iwao Nakamura (Hino Municipal Hospital), Shunsuke Takagi, Takashi Matsubara (Hiratsuka City Hospital), Masashi Takahashi, Keishu Li, Koichiro Sueyoshi (Kawasaki City Municipal Hospital), Taku Inohara, Atsushi Anzai, Kentaro Hayashida, Takashi Kawakami, Hideaki Kanazawa, Takahide Arai, Shunsuke Yuasa, Jun Fujita, Yuichiro Maekawa, Akio Kawamura (Keio University School of Medicine), Masahiro Suzuki (National Hospital Organization Saitama National Hospital) Yukinori Ikegami, Yukihiko Momiyama (National Hospital Organization Tokyo Medical Center), Ayaka Endo, Taku Hasegawa, Toshiyuki Takahashi, Susumu Nakagawa (Saiseikai Central Hospital), Takashi Yagi, Kenichiro Shimoji, Sonhan Yun, Takeshi Onitsuka, Shigetaka Noma (Saiseikai Utsunomiya Hospital), Yuji Nagatomo, Shiro Ishikawa (Saitama City Hospital), Atsushi Mizuno, Yutaro Nishi (St Luke’s International Hospital Heart Center), Masaru Shibata, Takashi Koyama (Tachikawa Kyosai Hospital), Kimi Koide, Yoshinori Mano, Takahiro Oki (Tokyo Dental College Ichikawa General Hospital), Daisuke Shinmura, Kouji Negishi (Yokohama Municipal Citizens Hospital).

Clinical Coordinators: Junko Susa, Ayano Ishikawa, Hiroaki Nagayama, Miho Umemura, Itsuka Saito,Kiri Shimauchi, Sachiko Koike, and Ikuko Ueda.

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Endo, A., Kohsaka, S., Miyata, H. et al. Disparity in the Application of Guideline-Based Medical Therapy after Percutaneous Coronary Intervention: Analysis from the Japanese Prospective Multicenter Registry. Am J Cardiovasc Drugs 13, 103–112 (2013). https://doi.org/10.1007/s40256-013-0021-8

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