Vanessa S Reddy

Transforming Quality of Care and Improving Outcomes After Acute MI: Lessons From the National Registry of Myocardial Infarction

THE NATIONAL REGISTRY OF MYOCARDIAL INFARCTION (NRMI) was the leading cardiovascular disease (CVD) patient registry from 1990 to 2006 in both size and duration. Notably, the various analyses and publications that resulted from the NRMI had direct and substantial effects in improving quality care for acute myocardial infarction (AMI) treatment in the United States. The NRMI has provided important lessons regarding effectiveobservational studydesign, implementationandanalysis, and the use and communication of findings pertinent to the broader clinical and research community. At the intersection between comparative effectiveness research and clinical quality improvement, the NRMI serves as a template for the development of future registries and large observational studies. Although CVD continues to be the leading cause of death in the United States, major advances in AMI management, such as the introduction of thrombolytic therapy (1980s) and advanced invasive primary angioplasty techniques (1990s), have mitigated the disease burden over recent decades. These therapeutic milestones coincided with important changes in the US health care system, with demands for higher-quality and more uniform care across hospitals. However, clinical observational tools and data infrastructure necessary for quality measurement, such as databases and registries, were lacking at local and national levels. Development of the NRMI was a step toward clinical measurement required to quantify this significant unmet medical need and evaluate effectiveness of existing and emerging AMI therapies.

Previous Myocardial Infarction as a Risk Factor for In-Hospital Cardiovascular Outcomes (from the National Registry of Myocardial Infarction 4 and 5)

Patients with acute coronary syndromes have a substantial disease burden and are at continued risk of future cardiovascular events. In this setting, the relation between previous myocardial infarction (MI) and the risk of subsequent in-hospital adverse cardiovascular outcomes has not been definitively established. The data were analyzed from 427,778 hospitalized patients presenting with acute MI from July 2002 to December 2006, who were enrolled in the National Registry of Myocardial Infarction 4-5 study. Multivariate logistic regression models were developed to examine the association between a history of MI and in-hospital all-cause mortality, recurrent MI, and congestive heart failure/pulmonary edema. Covariate adjustments were made for demographic characteristics, co-morbidities, prearrival medications, and health status at presentation. Similarly, multivariate linear regression models were used to evaluate the length of stay. Of the 232,927 patients with acute MI included in the present study after exclusions, 24.7% reported a history of MI. In-hospital mortality was not significantly different between the patients with and without a history of MI (adjusted odds ratio 0.99, 95% confidence interval 0.95 to 1.04, p = 0.75). However, patients with a previous MI had a small increased risk of in-hospital recurrent MI (adjusted odds ratio 1.18, 95% confidence interval 1.08 to 1.29, p <0.001) and congestive heart failure/pulmonary edema (adjusted odds ratio 1.23, 95% confidence interval1.19 to 1.28, p <0.001) compared with patients with no history of MI. In conclusion, a history of MI did not significantly affect in-hospital mortality after admission for an acute MI.

GW24-e3018 Long-term Medication Adherence Following Acute Coronary Syndrome in Patients with and without Recurrent Cardiovascular Events: Analysis of the HealthCore Integrated Research Database 2006–2011

Objectives Medication adherence is critical for the management of chronic disorders such as cardiovascular disease. However, long-term adherence has not been well described in acute coronary syndrome patients. The aim of this study is to assess long-term medication adherence to guideline-recommended treatments following acute coronary syndrome in patients with and without recurrent cardiovascular events. Methods Acute coronary syndrome patients hospitalised with an ICD-9 code for acute myocardial infarction or unstable angina were identified from the HealthCore Integrated Research Database (HIRDSM) between January 2006 and September 2011. Mean medication possession ratios for guideline-recommended acute coronary syndrome treatments were assessed 1 and 3 years after the index acute coronary syndrome using pharmacy claims data, stratified by presence or absence of recurrent cardiovascular events, defined as stroke, myocardial infarction or coronary heart disease-related mortality. Results Of the 140,903 acute coronary syndrome patients identified, 22% had > 1 recurrent cardiovascular event and were on average older (72.4 versus 65.2 years), included more women (44.5 versus 40.6%), and had more comorbidities (e.g. diabetes mellitus 49.7 versus 39.7%) as compared to those without recurrent events. After 3 years, patients were most adherent to antihypertensives (medication possession ratio = 0.70). The medication possession ratio ranged from 0.53 to 0.70 among different guideline-recommended treatments for patients with acute coronary syndrome. Overall, differences in medication possession ratios in patients with versus without recurrent events were small, although some were statistically significant. Conclusions At 3 years, medication adherence was highest to antihypertensives. The gaps in adherence highlight the need to encourage and monitor treatment use following acute coronary syndrome, as well as understand class-specific adherence barriers, to improve long-term outcomes.