Pharmacological Treatment Following Myocardial Infarction: How Large Is the Gap Between Guideline Recommendations and Routine Clinical Care?

Abstract

By now, more than one decade has passed since publication of guidelinerelevant landmark studies investigating the prognostic role of important pharmacotherapies (ie, beta blockers, inhibitors of the renin angiotensin aldosterone system, and mineralocorticoid receptor antagonists [MRA]) for primary prevention of sudden cardiac death.1 However, because of improvement of the nationwide healthcare supply, revascularization strategies of coronary artery disease, and increasing supply of invasive cardiac devices (such as an implantable cardioverter defibrillator or cardiac resynchronization therapy), mortality rates following acute myocardial infarction (AMI) have significantly decreased.1 As a consequence, characteristics and comorbidities of patients admitted to hospital have changed, leading to a higher number of older patients with increasing rates of progressive heart failure, complex coronary artery disease, atrial fibrillation, diabetes mellitus, and chronic kidney disease. Curiously, whether one of these established pharmacotherapies may still affect prognosis in patients with current complex heart failure syndromes has not yet been reevaluated within further randomized controlled trials. Therefore, European guidelines demand registry data to reassess the prognostic impact of established pharmacotherapies nowadays.1 To further close this gap in literature, Goldberger et al and Wong et al investigated the prognostic impact of beta blockers and their appropriate dose, as well as the current use and guideline adherence of MRA treatment in patients with AMI within this issue of the Journal of the American Heart Association (JAHA).2,3 Goldberger et al analyzed retrospectively more than 3,000 patients originally enrolled in the OBTAIN (Outcomes of Betablocker Therapy After Myocardial Infarction) registry (2007– 2011) using propensity score matched cohorts.2 They demonstrated lowest mortality rates in the presence of beta blocker intake of at least 12.5% to 25% of recommended target dosages at a median followup of one year. Their findings are in line with results from the SWEDEHEART (Swedish WebSystem for Enhancement and Development of EvidenceBased Care in Heart Disease Evaluated According to Recommended Therapies) registry (2006– 2015) demonstrating target dosages at more than 50% than recommended were not associated with improved freedom from reinfarction or allcause mortality.4 Despite the utmost importance of the