title: Longitudinal persistence with secondary prevention therapies relative to patient risk after myocardial infarction.
abstract: BACKGROUND
  Prior studies have demonstrated that patients with high-risk acute myocardial infarction (AMI) are less likely to receive guideline-directed medications during hospitalisation. It is unknown if this paradox persists following discharge. We aimed to assess if persistence with guideline-directed medications post discharge varies by patients' risk following AMI.
  
  
  METHODS
  Data were analysed from two prospective, multicentre US AMI registries. The primary outcome was persistence with all prescribed guideline-directed medications (aspirin, β-blockers, statins, angiotensin-antagonists) at 1, 6 and 12 months post discharge. The association between risk and medication persistence post discharge was assessed using multivariable mixed-effect models.
  
  
  RESULTS
  Among 6434 patients with AMI discharged home, 2824 were considered low-risk, 2014 intermediate-risk and 1596 high-risk for death based upon their Global Registry of Acute Coronary Event (GRACE) 6-month risk score. High-risk was associated with a lower likelihood of receiving all appropriate therapies at discharge compared with low-risk patients (relative risk (RR) 0.90; 95% CI 0.87 to 0.94). At 12 months, the rate of persistence with all prescribed therapies was 61.5%, 57.9% and 45.9% among low-risk, intermediate-risk and high-risk patients, respectively. After multivariable adjustment, high-risk was associated with lower persistence with all prescribed medications (RR 0.87; 95% CI 0.82 to 0.92) over follow-up. Similar associations were seen for individual medications. Over the 5 years of the study, persistence with prescribed therapies post discharge improved modestly among high-risk patients (RR 1.05; 95% CI 1.03 to 1.08 per year).
  
  
  CONCLUSIONS
  High-risk patients with AMI have a lower likelihood of persistently taking prescribed medications post discharge as compared with low-risk patients. Continued efforts are needed to improve the use of guideline-directed medications in high-risk patients.
authors: Emory University School of Medicine, Atlanta, Georgia, USA.
authors: Supriya
authors: S
authors: Shore
authors: Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.
authors: Philip G
authors: PG
authors: Jones
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, USA University of Colorado-School of Medicine, Aurora, Colorado, USA.
authors: Thomas M
authors: TM
authors: Maddox
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, USA University of Colorado-School of Medicine, Aurora, Colorado, USA.
authors: Steven M
authors: SM
authors: Bradley
authors: Saint Louis University, St Louis, Missouri, USA.
authors: Joshua M
authors: JM
authors: Stolker
authors: Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors: Suzanne V
authors: SV
authors: Arnold
authors: Emory University School of Medicine, Atlanta, Georgia, USA.
authors: Susmita
authors: S
authors: Parashar
authors: University of Colorado-School of Medicine, Aurora, Colorado, USA Denver Health Medical Center, Denver, Colorado, USA.
authors: Pamela
authors: P
authors: Peterson
authors: Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
authors: Deepak L
authors: DL
authors: Bhatt
authors: Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA University of Missouri-Kansas City, Kansas City, Missouri, USA.
authors: John
authors: J
authors: Spertus
authors: Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado, USA University of Colorado-School of Medicine, Aurora, Colorado, USA.
authors: P Michael
authors: PM
authors: Ho
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D047228:Angiotensin II Type 1 Receptor Blockers / Q000627:therapeutic use; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D001241:Aspirin / Q000627:therapeutic use; D002317:Cardiovascular Agents / Q000627:therapeutic use*; D016009:Chi-Square Distribution; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000175:diagnosis / Q000188:drug therapy* / Q000401:mortality; D016017:Odds Ratio; D010975:Platelet Aggregation Inhibitors / Q000627:therapeutic use; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians'; D012008:Recurrence; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D055502:Secondary Prevention / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
chemical_list: D000319:Adrenergic beta-Antagonists; D047228:Angiotensin II Type 1 Receptor Blockers; D000806:Angiotensin-Converting Enzyme Inhibitors; D002317:Cardiovascular Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin