title: Beyond medication prescription as performance measures: optimal secondary prevention medication dosing after acute myocardial infarction.
abstract: OBJECTIVE
  The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI).
  
  
  BACKGROUND
  Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether patients receive optimal dosing of secondary prevention medications at the time of and after discharge after AMI is unknown.
  
  
  METHODS
  We assessed treatment doses of beta-blockers, statins, and angiotensin-converting enzyme inhibitors (ACEI)/angiotensin II receptor blockers (ARBs) at discharge and 12 months after AMI among 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008). Prescribed doses were categorized as none, low (<50% target [defined from seminal clinical trials]), moderate (50% to 74% target), or goal (≥ 75% target). Patients with contraindications were excluded from analyses for that medication.
  
  
  RESULTS
  Most eligible patients (>87%) were prescribed some dose of each medication at discharge, although only 1 in 3 patients were prescribed these medications at goal doses. Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently (approximately 25% of patients for each medication). At 12 months, goal doses of beta-blockers, statins, and ACEI/ARBs were achieved in only 12%, 26%, and 32% of eligible patients, respectively. After multivariable adjustment, prescription of goal dose at discharge was strongly associated with being at goal dose at follow-up: beta-blockers, adjusted odds ratio (OR): 6.08 (95% confidence interval [CI]: 3.70 to 10.01); statins, adjusted OR: 8.22 (95% CI: 6.20 to 10.90); ACEI/ARBs, adjusted OR: 5.80 (95% CI: 2.56 to 13.16); p < 0.001 for each.
  
  
  CONCLUSIONS
  Although nearly all patients after an AMI are discharged on appropriate secondary prevention medications, dose increases occur infrequently, and most patients are prescribed doses below those with proven efficacy in clinical trials. Integration of dose intensity into performance measures might help improve the use of optimal medical therapy after AMI.
authors: Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri. Electronic address: suz.v.arnold@gmail.com.
authors: Suzanne V
authors: SV
authors: Arnold
authors: John A
authors: JA
authors: Spertus
authors: Frederick A
authors: FA
authors: Masoudi
authors: Stacie L
authors: SL
authors: Daugherty
authors: Thomas M
authors: TM
authors: Maddox
authors: Yan
authors: Y
authors: Li
authors: John A
authors: JA
authors: Dodson
authors: Paul S
authors: PS
authors: Chan
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage*; D047228:Angiotensin II Type 1 Receptor Blockers / Q000008:administration & dosage*; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000188:drug therapy* / Q000453:epidemiology; D011446:Prospective Studies; D012042:Registries; D055502:Secondary Prevention / Q000379:methods*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000319:Adrenergic beta-Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors
keywords: ACEI; AMI; ARB; CI; LDL-C; LV; OR; SBP; acute myocardial infarction; angiotensin II receptor blocker; angiotensin-converting enzyme inhibitor; confidence interval; left ventricular; low-density lipoprotein cholesterol; myocardial infarction; odds ratio; performance measures; secondary prevention; systolic blood pressure
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