Missed opportunities in the secondary prevention of myocardial infarction: an assessment of the effects of statin underprescribing on mortality.
BACKGROUND
The benefits of statins for the secondary prevention of coronary heart disease are well established. Previous research indicates that patients at the greatest risk of cardiovascular events are the least likely to receive statins. We explored the potential reduction in mortality at the population level that could result from improving statin prescribing among patients least likely to be prescribed a statin after acute myocardial infarction (AMI).


METHODS
Simulation analysis of detailed clinical data for a population-based sample of 7285 AMI survivors discharged from 102 hospitals between April 1, 1999, and March 31, 2001 in Ontario, Canada, was done. Using estimates obtained from randomized controlled trials, we estimated the reduction in 3-year all-cause mortality associated with improved statin prescribing at hospital discharge.


RESULTS
Overall, 35.6% of patients received a statin prescription at hospital discharge. We estimate that increasing statin prescribing among patients least likely to receive them (ie, the lowest quintile of propensity to receive a prescription at discharge) from the current rate of 7.8% to the rate among all patients (35.6%) could decrease AMI mortality by 83 deaths in Ontario per year (2.1% of all post-AMI deaths within 3 years of discharge). Increasing statin prescribing to 70% among all patients with AMI could avert 312 deaths per year in Ontario. Factoring in low rates of adherence to statin therapy would reduce these estimates to 33 and 126, respectively.


CONCLUSIONS
Modest increases in statin prescribing for patients least likely to receive one could decrease post-AMI mortality at the population level.
Austin
Peter C
PC
Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada. peter.austin@ices.on.ca
Mamdani
Muhammad M
MM
Juurlink
David N
DN
Alter
David A
DA
Tu
Jack V
JV
D000368:Aged; D000369:Aged, 80 and over; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006760:Hospitalization; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D009026:Mortality; D009203:Myocardial Infarction / Q000188:drug therapy / Q000401:mortality* / Q000517:prevention & control* / Q000628:therapy*; D010351:Patient Discharge; D012189:Retrospective Studies
D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors