Underuse of aspirin in a referral population with documented coronary artery disease

Califf, Robert M.; DeLong, Elizabeth R.; Østbye, Truls; Muhlbaier, Lawrence H.; Chen, Anita; Lapointe, Nancy Allen; Hammill, Bradley G.; McCants, Charles B.; Kramer, Judith M.

doi:10.1016/s0002-9149(01)02335-9

Cited by 54 publications

(30 citation statements)

References 17 publications

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“…Our results also confirm earlier studies that have shown the use of evidence-based pharmacotherapies to diminish paradoxically with increasing baseline risk of future events (6,8,11,13,14,38,39,(43)(44)(45)(46). While the magnitude of effect for baseline risk on the use of reperfusion therapy was modest, the relationship was independent of age and hospital arrival times -both of which have also been shown to be independent predictors of reperfusion therapy use.…”

Section: Discussionsupporting

confidence: 90%

“…Accordingly, physicians should be most enthusiastic and assiduous about the use of evidence-based therapies in high-risk patients who have the most to gain. This has not been the case for many therapies, where an inverse relationship between baseline risk and application of treatment has been shown (3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13). For example, in the cardiovascular field, elderly patients, patients with lower socioeconomic status and those with greater comorbidity undergo fewer cardiac interventions and may be less likely to receive beta-blockers, acetylsalicylic acid and statins following acute myocardial infarction (AMI), even though these patients have the most to gain (3,4,(6)(7)(8)(9)(10)14).…”

mentioning

confidence: 99%

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Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Parker

Naylor

Chong

et al. 2006

Canadian Journal of Cardiology

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BACKGROUND: Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined. METHODS: Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated riskadjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status. RESULTS: Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P<0.001). The number rather than the type of pre-existing conditions inversely correlated with the use of reperfusion therapy. While the impact of baseline risk and pre-existing conditions was additive, pre-existing conditions exerted a greater impact on the nonuse of reperfusion therapy than did baseline risk. CONCLUSIONS: A treatment-risk paradox is demonstrable even within a cohort of lower risk patients with ST segment elevation myocardial infarction. These findings are consistent with the view that these clinical decisions are more likely to be attributable to concerns about patient frailty or side effects than to a misunderstanding of treatment benefits.

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Section: Discussionsupporting

confidence: 90%

mentioning

confidence: 99%

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Parker

Naylor

Chong

et al. 2006

Canadian Journal of Cardiology

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show abstract

“…As demonstrated in Table 2 and Table 3 and in our previous work from the DDCD, 21 a number of measured factors were associated either positively or negatively with consistent, long-term use of these proven therapies. However, it is concerning that consistent use of evidence-based medications was paradoxically lower among groups with the highest risk of poor outcomes and therefore who could potentially benefit the most from sustained therapy.…”

Section: Characteristics Associated With Use Of Proven Therapiesmentioning

confidence: 56%

Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease

et al. 2006

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Background-Studies have examined the use of evidence-based therapies for coronary artery disease (CAD) in the short term and at hospital discharge, but few have evaluated long-term use. Methods and Results-Using the Duke Databank for Cardiovascular Disease for the years 1995 to 2002, we determined the annual prevalence and consistency of self-reported use of aspirin, ␤-blockers, lipid-lowering agents, and their combinations in all CAD patients and of angiotensin-converting enzyme inhibitors (ACEIs) in those with and without heart failure. Logistic-regression models identified characteristics associated with consistent use (reported on Ն2 consecutive follow-up surveys and then through death, withdrawal, or study end), and Cox proportional-hazards models explored the association of consistent use with mortality. Use of all agents and combinations thereof increased yearly.

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“…Although the specifics vary regarding beta blockers and other drugs (150,734,741), a consistent (and disturbing) pattern is that women are prescribed ASA and other antithrombotic agents less frequently than men (150,737,740). Women derive the same treatment benefit as men from ASA, clopidogrel (54), anticoagulants, beta blockers, ACE inhibitors, and statins (54,742).…”

Section: Pharmacological Therapymentioning

confidence: 99%

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

Anderson

Adams²,

Antman³

et al. 2007

Circulation

1,236

490

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Underuse of aspirin in a referral population with documented coronary artery disease

Cited by 54 publications

References 17 publications

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction

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