Abstract 14951: Use of Aldosterone Antagonists at Discharge after Myocardial Infarction: Results from the NCDR

Abstract

Background: Aldosterone antagonists (AAs) improve survival after MI in patients with left ventricular systolic dysfunction (EF<40%) and either clinical evidence of heart failure or diabetes. Although current ACC/AHA guidelines provide a class IA recommendation for AA therapy in eligible patients without contraindication, the extent to which U.S. clinical practice reflects these guideline recommendations has not been reported.

Methods: Using the NCDR ACTION Registry®-GWTG™ (AR-G), we describe contemporary discharge AA prescription patterns among guideline-eligible patients, stratified by specific clinical indication, and in relation to performance on discharge prescription quality metrics. Patients who presented in shock, who were transferred out, or who died were excluded.

Results: Among 202,213 acute MI patients discharged from 526 U.S. hospitals enrolled in AR-G between January 2007 and March 2011, 20,272 (10.0%) were guideline-eligible and without contraindication for AA prescription (11.2% of NSTEMI, 8.3% of STEMI). Of these, only 14.5% were prescribed AA (14.2% of NSTEMI, 15.1% of STEMI). AA prescription was especially low in patients with diabetes and EF<40%, but without clinical heart failure (7.8%), compared to patients with EF<40% and clinical heart failure with or without diabetes (17.7% and 16.6%, respectively). Among AA-eligible patients, other guideline-indicated medications were prescribed at rates far exceeding those of AA (figure).

Conclusions: Despite clinical trial evidence and class IA guideline recommendations, AA are underutilized in the U.S., with only 1 in 7 guideline-eligible patients prescribed AA on discharge after MI. This contrasts with high utilization of other evidence-based post-MI medications, and identifies a specific gap in translation of guideline recommendations into clinical practice.