(Circulation. 2001;103:38.)
© 2001 American Heart Association, Inc.
Clinical Investigation and Reports |
Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction
Data From the National Registry of Myocardial Infarction 3
From the Ahmanson-UCLA Cardiomyopathy Center (G.C.F.), UCLA Division of Cardiology, and the Harbor-UCLA Medical Center (W.J.F.), Los Angeles, Calif, and the Cardiovascular Outcomes Research Center (L.S.P., H.S., J.A.M.), University of Washington.
Correspondence to Gregg C. Fonarow, MD, Ahmanson-UCLA Cardiomyopathy Center, UCLA Division of Cardiology, 47-123 CHS, 10833 Le Conte Ave, Los Angeles, CA 90095-1679. E-mail gfonarow{at}mednet.ucla.edu
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Abstract |
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Background—The present study aimed to assess use of lipid-lowering medication at discharge in a current national sample of patients hospitalized with acute myocardial infarction and to evaluate factors associated with prescribing patterns.
Methods and Results—Demographic, procedural, and discharge medication data were collected from 138 001 patients with acute myocardial infarction discharged from 1470 US hospitals participating in the National Registry of Myocardial Infarction 3 from July 1998 to June 1999. Lipid-lowering medications were part of the discharge regimen in 31.7%. Among patients with prior history of CAD, revascularization, or diabetes, less than one half of the patients were discharged on treatment. In multivariate analysis, factors independently related to lipid-lowering use included history of hypercholesterolemia (odds ratio [OR] 4.93; 95% CI 4.79 to 5.07), cardiac catheterization during hospitalization (OR 1.29; 95% CI 1.24 to 1.34), care provided at a teaching hospital, (OR 1.26; 95% CI 1.22 to 1.32), use of ß-blocker (OR 1.43; 95% CI 1.39 to 1.48), and smoking cessation counseling (OR 1.51; 95% CI 1.44 to 1.59). Lipid-lowering medications were given less often to patients who were older (65 to 74 versus <55 years of age; OR 0.82; 95% CI 0.78 to 0.86), those with a history of hypertension (OR 0.92; 95% CI 0.89 to 0.95), and those undergoing coronary artery bypass graft surgery (OR 0.58; 95% CI 0.55 to 0.60).
Conclusions—Analysis of current practice patterns for the use of lipid-lowering medications in patients hospitalized with acute myocardial infarction reveals that a significant proportion of high-risk patients did not receive treatment at time of discharge.
Key Words: myocardial infarction • risk factors • hypercholesterolemia • lipids
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Introduction |
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Compelling scientific evidence suggests that lipid-lowering therapy reduces the risk of recurrent coronary events and improves survival in patients after myocardial infarction (MI).1 2 3 4 5 Benefits of lipid-lowering medications apply to both men and women, to patients older and younger than 65 years of age, and to diabetics.6 7 8 9 The magnitude of benefit with lipid-lowering medications matches or exceeds benefits with other secondary prevention medications, such as aspirin, ß-blockers, and angiotensin-converting enzyme (ACE) inhibitors, in the patient after MI.3 10
Despite the effectiveness of lipid-lowering therapy in altering subsequent cardiovascular mortality, several prior studies have documented low treatment rates in patients with established coronary artery disease (CAD).11 12 13 14 15 16 Many of these studies involved patients from a single or a limited number of centers, enrolled in randomized clinical trials, or treated before dissemination of the most convincing clinical trial evidence. Use of lipid-lowering medications in the post-MI setting represents a major clinical practice and public health issue, with factors predicting use not previously studied in a large national patient data set. The purpose of the present study was to evaluate recent physician practice patterns of prescription of lipid-lowering medications to patients hospitalized for acute MI (AMI) and the clinical characteristics, practices, and institutional factors associated with such use.
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Methods |
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The National Registry of Myocardial Infarction (NRMI) 3 is a prospective, observational study of patients admitted to the hospital with AMI that was initiated April 1998. Hospitals participating in the registry enroll consecutive patients with AMI as previously described.17 Methods used for AMI diagnosis, case ascertainment, and data acquisition by the NRMI 3 are similar to the ones used by the NRMI 2 registry, which were validated previously.18
Measurements
Detailed demographic data were collected and included
age, sex, race, and past medical history (history of stroke, history of
heart failure, prior coronary angioplasty, prior CABG, history of
congestive heart failure, history of angina, and previous MI). Risk
factors for CAD were assessed, including history of diabetes mellitus,
history of hypertension, history of hypercholesterolemia, and current
tobacco usage. Initial diagnosis of the patient on presentation and
location and type of AMI were recorded. Primary medical insurance of
the patient was classified as commercial/preferred provider
organization (PPO), Medicare, health maintenance organization (HMO),
medicaid, self-pay/uninsured, or other. Because patients with Medicare
may have additional primary or secondary insurance and this affects
prescription medication benefits, patients with Medicare alone and
Medicare with commercial/PPO (Medicare–non-HMO) were compared with
patients with Medicare-HMO. Hospital characteristics classified by bed
size, type (urban versus rural, teaching versus nonteaching, and
noninvasive versus cardiac catheterization without cardiac surgery
versus with cardiac surgery), and geographic location were also
recorded. Use of the following cardiac procedures were reported:
echocardiography, coronary angiography, PTCA, and in-hospital CABG. Use
of the following medications within 24 hours of diagnosis was
collected: aspirin, thrombolytic agent, ß-blocker, ACE inhibitor,
heparin, and calcium channel blocker. Medications prescribed at
hospital discharge were ascertained: aspirin, ß-blockers, calcium
blockers, nitrates, and prescription lipid-lowering medications.
Smoking cessation counseling in current smokers was also abstracted
from the medical record.
Statistical Analysis
Baseline demographics, use of medications,
institutional variables, and use of cardiac procedures were compared
with the outcome of interest, lipid-lowering medication prescribed at
discharge. 
2 and Student’s
t tests were performed to
determine whether significant associations existed. A stepwise logistic
regression model was developed to identify predictors of receiving
lipid-lowering medical therapy at discharge. Variables included in the
model were chosen on the basis of univariate statistical significance
and clinical importance. The model included all variables shown in
Tables 1 to 3
. Adequacy of fit and discriminatory power of
the model were assessed according to standard methods. Odds ratios and
95% confidence intervals are reported for the model. All tests of
statistical significance were 2-tailed. All statistical calculations
were performed with SAS software version 6.12
(SAS Institute Inc).
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Results |
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From July 1, 1998, to June 30, 1999, a total of 199 450 patients from 1470 US hospitals registered in NRMI 3 had been enrolled. In the current analysis, 42 830 (21.5%) patients that were transferred from a participating registry hospital to another acute-care institution were excluded because medication at discharge information was not available. In addition, 18 619 (9.3%) patients who died during the hospital period were excluded from the analysis. The final study cohort consisted of 138 001 patients.
Univariate Analysis
Baseline demographic and clinical characteristics by
lipid-lowering medication treatment at discharge are shown in
Table 1
. In this cohort of patients being discharged from
the hospital after AMI, only 31.7% were prescribed lipid-lowering
medications. Patients prescribed lipid-lowering medications at
discharge were significantly younger (average age, 63.4 years) than
patients not treated with lipid-lowering medications (average age, 70.1
years; P<0.0001). There was a
marked decline in prescription of therapy with advancing age.
Lipid-lowering treatment rates were 43.6% in patients age <55 years,
33.4% in patients ages 65 to 75 years, 22.8% in patients ages 75 to
84 years, and 9.7% in patients age 85+ years. Women were less likely
to be treated with lipid-lowering medications: 34.8% of men were
discharged on lipid-lowering therapy compared with 26.8% of women.
This difference was not entirely due to differences in age of
presentation with AMI
(Figure).
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Patient and hospital characteristics are shown in
Table 2. Although patients with documented prior history of
CAD were more likely to be discharged on lipid-lowering therapy than
those without previous cardiac history, substantial proportions of
these patients were still not treated. In patients with previous
history of AMI, 65.1% were discharged without lipid-lowering therapy
after having 
2 MIs. In patients with previous CABG, 57.4% were sent
home without treatment, as were 54.6% of patients with previous
PTCA.
In this AMI patient population, 32.2% of patients were documented as having a medical history of hypercholesterolemia. Patients with a history of hypercholesterolemia were more likely to be discharged on lipid-lowering medications. Still, 41.7% of these patients were discharged without documented treatment. Despite being at higher risk and standing to receive greater benefit from treatment, patients with diabetes mellitus were not more likely to be treated with lipid-lowering medications: treatment use occurred in only 31.6% of diabetes versus 31.7% of nondiabetics (P=NS). Patients with history of stroke and heart failure were less likely to be treated.
Patients with Medicare–non-HMO insurance were substantially less likely to be treated than patients with Medicare-HMO. Interestingly, no significant differences were seen between commercial/PPO, HMO, Medicaid, and self-pay/uninsured patient treatment rates. Teaching hospitals had a significantly higher rate of providing lipid treatment than did nonteaching hospitals (39.4% versus 30.3%; P<0.0001).
Patients undergoing coronary angiography and PTCA during the
AMI hospitalization were more likely to receive lipid-lowering
medications, whereas patients undergoing CABG were significantly less
likely
(Table 3). Patients who received other secondary medications
at discharge (aspirin, ß-blocker, or ACE inhibitors) were more likely
to be treated with lipid-lowering medications. Only 40.6% of current
smokers received documented smoking cessation counseling, but these
patients were more likely to receive lipid treatment than current
smokers that did not receive counseling (45.7% versus 28.0%;
P<0.0001).
Multivariate Analysis
To evaluate which clinical, demographic, hospital, and
process-of-care–related factors independently influenced use of
lipid-lowering medications at the time of discharge, a multivariate
logistic regression model was constructed with all variables in
Tables 1 to 3. Independent predictors of use of
lipid-lowering therapy included younger age, previous MI, previous PTCA
or CABG, and history of hypercholesterolemia, as shown in
Table 4. Odds of receipt of lipid-lowering treatment in
patients ages 75 to 84 was 0.59 (95% CI 0.56 to 0.62) compared with
patients age <55 years. Hypertension was associated with an 0.92 (95%
CI 0.89 to 0.95) odds ratio of being discharged on lipid therapy, and a
current history of smoking was associated with one of 0.79 (95% CI
0.76 to 0.82).
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Receiving cardiac catheterization or PTCA during hospitalization for AMI was an independent predictor for receiving lipid-lowering medications. Administration of thrombolytic therapy was not predictive, and receiving CABG during AMI hospitalization was associated with a substantially lower likelihood of receiving lipid therapy (odds ratio 0.58). Receiving smoking cessation counseling during hospitalization with AMI among current smokers was associated with an odds ratio of 1.51 (95% CI 1.44 to 1.59), which indicates a strong association between use of these 2 secondary prevention measures.
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Discussion |
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Despite widespread dissemination of national treatment guidelines and publicized results of major clinical trials on the value of lipid-lowering medications in the secondary prevention of coronary heart disease, the present study found that only one third of patients hospitalized with AMI were discharged on lipid-lowering medications as recorded in the medical record. A variety of clinical, demographic, treatment, and process-of-care factors that significantly influenced treatment use of lipid-lowering medications were identified.
Elderly patients, independent of associated comorbidities,
were at increased risk of being discharged without lipid-lowering
therapy. Elderly patients face a higher risk of recurrent MI and death
than younger patients.7
Although some question has arisen regarding the association between
elevated cholesterol and cardiovascular risk in the elderly, individual
clinical trials and meta-analysis have supported that patients age 65
years with established CAD derive substantial benefit from
lipid-lowering medications.7
Young women were less likely to be treated with lipid-lowering
medications than young men, but after adjustment of other variables,
sex of the patient was only a minor independent predictor of not
receiving lipid treatment.
As expected, patients with prior medical history of hypercholesterolemia were more likely to be discharged on lipid-lowering therapy. Still, 41.7% of patients who had a previously documented history of hypercholesterolemia and had sustained an AMI, were discharged without medical treatment. The Long-Term Intervention with Pravastatin in Ischemic Disease (LIPID) trial demonstrated that in patients after MI or unstable angina with baseline cholesterol levels of 155 to 271 mg/dL, a substantial reduction occurs in all-cause mortality when a lipid-lowering medication (HMG-CoA reductase inhibitor) is added to modified diet alone.5 This trial and other studies clearly demonstrate that post-MI patients with lipid levels that would not be classified as hypercholesterolemic derive significant benefit from lipid-lowering medical treatment.
Patients undergoing cardiac catheterization and PTCA were more likely to be discharged on lipid-lowering medications. This result was independent of other patient and hospital characteristics and suggests that the extra medical personnel and attention that these patients were exposed to favorably affected treatment rates. Patients at teaching hospitals had a greater likelihood of receiving treatment. Patients discharged on other evidence-based therapies of aspirin, ß-blockers, or ACE inhibitors also were more likely to be discharged on a lipid-lowering medication. Likewise, current smokers treated by physicians and nurses that provided smoking cessation counseling during hospitalization were more likely to be discharged on lipid-lowering medication. These associations indicate that administration of lipid-lowering medications is affected by physician education and the process of care in place within the hospital and could be favorably affected by educational initiatives and quality-improvement projects. Prior studies have demonstrated improvements in hospital treatment use rates for other secondary prevention measures such as aspirin or ß-blockers in AMI patients through use of educational programs.19
Patients enrolled in managed care were slightly more likely to receive lipid-lowering therapy than patients with other insurance, a result that is similar to those of previous studies.15 Patients enrolled in Medicare alone or combined with commercial/PPO insurance were less likely to receive lipid-lowering therapy. Even after adjusting for differences in age, comorbidity, and other factors, this effect was apparent. These data suggest that prescription drug coverage may significantly improve lipid-lowering medication treatment rates in the Medicare patient population.
NRMI 3 collected data on use of lipid-lowering medications at the time of hospital discharge, and it is not possible to determine the frequency at which therapy was begun after hospital discharge. Many patients may have been started on lipid-lowering medications after discharge. However, numerous studies have demonstrated a significant failure to implement treatment in the outpatient setting in patients with coronary heart disease.11 12 13 14 15 16 Approximately one half of the patients in the present study had established CAD before admission for AMI and would have been previously eligible for lipid-lowering medication. Admission for AMI may be associated with previous failure to implement secondary prevention measures. Other studies of a more limited scope have demonstrated low treatment rates in patients after MI. In a study at a single university hospital in 1996, Frolkis et al12 demonstrated that 36% of patients were treated with lipid-lowering medications at the time of discharge after being hospitalized with CAD. An analysis of elderly patients hospitalized for AMI in 37 community hospitals in Minnesota from 1995–1996 showed a treatment rate of 37% at time of discharge in patients with cholesterol levels >200 mg/dL.15
Treatment guidelines and algorithms such as the NCEP have
recommended delaying baseline lipid assessment and treatment until 6
weeks after acute presentation in recognition that the acute-phase
response triggered by AMI can substantially lower total and LDL
cholesterol.20 As a result,
the first opportunity for beginning treatment is delayed to a time at
which the patient may no longer be focused on their underlying
atherosclerotic disease process and to a setting with less resources.
It has been suggested that evidence of CAD alone is sufficient
to begin administration of lipid-lowering medications with or without
baseline lipid
levels.21 22 The
fact that lipid panels obtained in the first 24 hours of hospital
admission have been shown to accurately reflect steady-state lipid
levels at 6 weeks removes a substantial perceived barrier to initiating
lipid-lowering therapy in the hospital
setting.23 Diet alone is
unlikely to result in LDL <100 mg/dL in this patient
population.24 25
One study of post-MI patients showed 93% of the study patients
required lipid-lowering medications, given that their LDL level
remained >100 mg/dL at 90 days after discharge, despite intensive
diet, exercise counseling, and
monitoring.24 A 1997 AHA
Science Advisory on when to start cholesterol-lowering therapy in
patients with coronary heart
disease23 recommended that
cholesterol-reducing medication be considered for institution
simultaneously with nonpharmacologic therapy at time of hospital
discharge in patients with coronary heart disease and LDL 130 mg/dL.
Institution of lipid-lowering therapy in the in-patient setting has a
number of potential advantages. A Cardiac Hospitalization
Atherosclerosis Management Program (CHAMP) that focused on initiating
lipid-lowering medications before hospital discharge preliminarily was
reported to be associated with a marked increase in treatment rates,
improved patient compliance, and a greater number of patients achieving
LDL 
100
mg/dL.22
Study Limitations
Although the data collected were not independently
validated, methods of case ascertainment and acquisition of other data
from NRMI have been found to be
valid.18 Data on lipid levels
in individual patients are not available. Thus, it is not possible to
determine for a given patient the appropriateness of prescribing or not
prescribing lipid-lowering medications. However, on the basis of prior
studies in post-MI patients, in aggregate this population would be
expected to consist of a large proportion of patients that would
qualify for and derive substantial benefit from lipid-lowering
medications.11 12 15
Specific medications prescribed and doses and extent of dietary and
exercise counseling were not available in the present study. Use of a
lipid-lowering medication does not necessarily indicate that the
patient was treated with the most appropriate agent or dosage or that
the patient had achieved LDL 100 mg/dL. Prior studies have shown that
only 
30% to 40% of outpatients with CAD who received
lipid-lowering medications have achieved LDL 100
mg/dL.11 15
Conclusions
Despite compelling scientific evidence of the benefits
of lipid-lowering medications in patients with clinically evident CAD,
the present study documents that a substantial proportion of patients
after AMI are not discharged on treatment. A variety of clinical,
demographic, hospital, and process-of-care characteristics appear to
influence physician use of lipid-lowering treatment, which suggests
that educational programs and hospital-based treatment algorithms may
be effective for improvement of use of lipid-lowering medications in
patients after
MI.
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Acknowledgments |
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The National Registry of Myocardial Infarction 3 is supported by Genentech, Inc, South San Francisco, Calif.
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Footnotes |
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Dr French serves as an advisory board member of The National Registry of Myocardial Infarction (NRMI). In addition, Dr Fonarow serves as a consultant and speaker for Merck and Bristol-Myers Squibb.
A complete list of the participating hospitals is available from ClinTrials Research, 1100 Weston Pkwy, Cary, NC 27513.
Received June 8, 2000; revision received August 11, 2000; accepted August 14, 2000.
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O. Ben-Yehuda The cardiologist's toolbox: improving care J. Am. Coll. Cardiol., June 16, 2004; 43(12): 2174 - 2176. [Full Text] [PDF]
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K. A. LaBresh, A. G. Ellrodt, R. Gliklich, J. Liljestrand, and R. Peto Get With the Guidelines for Cardiovascular Secondary Prevention: Pilot Results Arch Intern Med, January 26, 2004; 164(2): 203 - 209. [Abstract] [Full Text] [PDF]
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V. G. Athyros, A. A. Papageorgiou, A. N. Symeonidis, T. P. Didangelos, A. N. Pehlivanidis, V. I. Bouloukos, and D. P. Mikhailidis Early Benefit from Structured Care with Atorvastatin in Patients with Coronary Heart Disease and Diabetes Mellitus: A Subgroup Analysis of the GREek Atorvastatin and Coronary Heart Disease Evaluation (GREACE) Study Angiology, November 1, 2003; 54(6): 679 - 690. [Abstract] [PDF]
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R. O. Bonow The Challenge of Balancing Scientific Discovery and Translation Circulation, January 28, 2003; 107(3): 358 - 362. [Full Text] [PDF]
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J. Muntwyler, G. Abetel, C. Gruner, and F. Follath One-year mortality among unselected outpatients with heart failure Eur. Heart J., December 1, 2002; 23(23): 1861 - 1866. [Abstract] [Full Text] [PDF]
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R. S. Wright, J. G. Murphy, K. A. Bybee, S. L. Kopecky, and J.-M. LaBlanche Statin Lipid-Lowering Therapy for Acute Myocardial Infarction and Unstable Angina: Efficacy and Mechanism of Benefit Mayo Clin. Proc., October 1, 2002; 77(10): 1085 - 1092. [Abstract] [PDF]
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E. J. Benjamin, S. C. Smith Jr, R. S. Cooper, M. N. Hill, and R. V. Luepker Task Force #1--magnitude of the prevention problem: opportunities and challenges J. Am. Coll. Cardiol., August 21, 2002; 40(4): 588 - 603. [Full Text] [PDF]
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P. A. Ades, T. E. Kottke, N. Houston Miller, J. C. McGrath, N. B. Record, and S. S. Record Task Force #3--getting results: who, where, and how? J. Am. Coll. Cardiol., August 21, 2002; 40(4): 615 - 630. [Full Text] [PDF]
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C G Isles Patients with acute coronary syndrome should start a statin while still in hospital Heart, July 1, 2002; 88(1): 5 - 6. [Full Text] [PDF]
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P G Steg, B Iung, L J Feldman, D Cokkinos, J Deckers, K A A Fox, U Keil, and A P Maggioni Impact of availability and use of coronary interventions on the prescription of aspirin and lipid lowering treatment after acute coronary syndromes Heart, July 1, 2002; 88(1): 20 - 24. [Abstract] [Full Text] [PDF]
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J. Yarzebski, C. F. Bujor, R. J. Goldberg, F. Spencer, D. Lessard, and J. M. Gore A Community-Wide Survey of Physician Practices and Attitudes Toward Cholesterol Management in Patients With Recent Acute Myocardial Infarction Arch Intern Med, April 8, 2002; 162(7): 797 - 804. [Abstract] [Full Text] [PDF]
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C. R. Lacy, D.-C. Suh, J. A. Barone, M. Bueno, D. Moylan, C. Swartz, R. V. Kudipudi, and J. B. Kostis Impact of a Targeted Intervention on Lipid-Lowering Therapy in Patients With Coronary Artery Disease in the Hospital Setting Arch Intern Med, February 25, 2002; 162(4): 468 - 473. [Abstract] [Full Text] [PDF]
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J. S. Zebrack, J. B. Muhlestein, B. D. Horne, J. L. Anderson, and Intermountain Heart Collaboration Study Group C-reactive protein and angiographic coronary artery disease: independent and additive predictors of risk in subjects with angina J. Am. Coll. Cardiol., February 20, 2002; 39(4): 632 - 637. [Abstract] [Full Text] [PDF]
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D. A. Vorchheimer and V. Fuster Inflammatory Markers in Coronary Artery Disease: Let Prevention Douse the Flames JAMA, November 7, 2001; 286(17): 2154 - 2156. [Full Text] [PDF]
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G. A. Beller Presidential address: quality of cardiovascular care in the U.S. J. Am. Coll. Cardiol., September 1, 2001; 38(3): 587 - 594. [Full Text] [PDF]
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G. C. Fonarow and C. M. Ballantyne In-Hospital Initiation of Lipid-Lowering Therapy for Patients With Coronary Heart Disease : The Time Is Now Circulation, June 12, 2001; 103(23): 2768 - 2770. [Full Text] [PDF]
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F. M. Sacks Lipid-Lowering Therapy in Acute Coronary Syndromes JAMA, April 4, 2001; 285(13): 1758 - 1760. [Full Text] [PDF]
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