title: Systematic underutilisation of secondary preventive drugs in patients with acute coronary syndrome and reduced renal function.
abstract: Aims The high risk of recurrent events in patients with reduced renal function following an acute coronary syndrome (ACS) may in part be due to suboptimal secondary prevention. We aimed to describe the association between renal dysfunction and the prescription, initiation and persistent use of secondary prevention during the first year after a first ACS. Methods We identified all patients admitted to any Swedish coronary care unit for a first ACS between 2005 and 2010 ( n = 77,432). In 75,129 patients, creatinine levels were available in order to obtain the estimated glomerular filtration rate (eGFR). Persistent use of prescribed drugs was determined for 1 year using the National Prescription Registry, with complete coverage of all prescribed and dispensed drugs in Sweden. Results After adjustment for relative and absolute contraindications, compared to patients with eGFR ≥ 60 mL/min/1.73 m2, patients with eGFR 30-59 had higher odds of not being prescribed acetylsalicylic acid (ASA; odds ratio [OR]: 1.56, 95% confidence interval [CI]: 1.47-1.67), statins (OR: 2.94, 95% CI: 2.86-3.13) or β-blockade (OR: 1.25, 95% CI: 1.18-1.32). Patients with eGFR 30-59 were more likely to discontinue treatment with ASA (hazard ratio [HR]: 1.59, 95% CI: 1.42-1.56), statins (HR: 1.35, 95% CI: 1.29-1.41), angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers (HR: 1.37, 95% CI: 1.31-1.43) or β-blockade (HR: 1.22, 95% CI: 1.18-1.27). Patients with eGFR < 30 showed a similar pattern in both prescription and discontinuation. Conclusion High-risk ACS patients with reduced renal function are less likely to be prescribed secondary prevention drugs at discharge, are less likely to initiate treatment when being prescribed these drugs, are less likely to be persistent in the use of these drugs and more often discontinue treatment.
authors.affiliation: 1 Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Masih
authors.initials: M
authors.lastname: Khedri
authors.affiliation: 2 Section of Cardiology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Karolina
authors.initials: K
authors.lastname: Szummer
authors.affiliation: 3 Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Juan-Jesus
authors.initials: JJ
authors.lastname: Carrero
authors.affiliation: 2 Section of Cardiology, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.|4 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Tomas
authors.initials: T
authors.lastname: Jernberg
authors.affiliation: 3 Division of Renal Medicine, CLINTEC, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Marie
authors.initials: M
authors.lastname: Evans
authors.affiliation: 5 Division of Nephrology, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Stefan H
authors.initials: SH
authors.lastname: Jacobson
authors.affiliation: 1 Division of Cardiovascular Medicine, Department of Clinical Sciences, Danderyd University Hospital, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Jonas
authors.initials: J
authors.lastname: Spaak
mesh_terms: D054058:Acute Coronary Syndrome / Q000188:drug therapy* / Q000453:epidemiology* / Q000517:prevention & control; D000368:Aged; D000369:Aged, 80 and over; D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage; D001241:Aspirin / Q000008:administration & dosage; D002316:Cardiotonic Agents / Q000008:administration & dosage; D015331:Cohort Studies; D016208:Databases, Factual; D004363:Drug Utilization / Q000706:statistics & numerical data*; D005260:Female; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage; D015994:Incidence; D007674:Kidney Diseases / Q000175:diagnosis* / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010351:Patient Discharge; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment; D055502:Secondary Prevention / Q000379:methods*; D012720:Severity of Illness Index; D016019:Survival Analysis; D013548:Sweden
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D002316:Cardiotonic Agents; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D001241:Aspirin
keywords: Myocardial infarction; adherence; chronic kidney disease; compliance; persistence