1 in 5 eligible ACS patients not receiving ACEI/ARBs

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 - heart attack

Although the American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend initiating ACEI/ARBs after MI, a study published online Feb. 25 in Circulation: Cardiovascular Quality and Outcomes found about one in five patients who meet the criteria for ACEI/ARB therapy do not receive it.

Senior author Deepak L. Bhatt, MD, MPH, of Brigham and Women’s Hospital Heart and Vascular Center in Boston, told Cardiovascular Business that the impetus behind the research was the clinical observation that ACEI/ARBs were not used in appropriate patients as often as anticipated. “They are used often in patients admitted with heart failure, but not in patients with ACS [acute coronary syndrome], which is an awareness issue,” Bhatt said.

To quantify the use of ACEI/ARBs at discharge in patients with ACS, Bhatt and colleagues used data from patients who participated in the Get With the Guidelines (GWTG)-coronary artery disease (CAD) program. GWTG-CAD is a registry designed with the goal of improving the quality of care and outcomes in patients with CAD.

They analyzed data from 80,241 patients with ACS who were discharged alive from 311 U.S. hospitals between 2005 and 2009. All participants were classified with an ACC/AHA class I or class IIa treatment indication who had no known contraindications to ACEI/ARB therapy.

Of the 60,847 patients with a class I indication, 49,682 received ACEI/ARBs (81.7 percent) and the rate of treatment increased throughout the study period. Only 68.1 percent of the 19,394 patients with an ACC/AHA class IIa indication were prescribed ACEI/ARBs.

Lower use was independently associated with in-hospital CABG and renal insufficiency. Patients with a class I indication more likely to be treated with ACEI/ARBs had a higher body mass index, a history of diabetes mellitus, CAD heart failure, smoked or underwent PCI. Those less likely to receive therapy were women, white and had a history of atrial fibrillation, lung disease or hypertension.

Patients with a class IIa indication more likely to receive ACEI/ARB therapy were older, had an MI in the past, smoked, underwent PCI or were in larger hospitals. Those less likely to be prescribed ACEI/ARBs were women; had a history of atrial fibrillation, hyperlipidemia, or depression; underwent CABG in the hospital or were admitted to academic hospitals. 

Bhatt said he hopes the findings will raise awareness about the use of ACEI/ARBs in ACS patients.

“If someone comes in with ACS, the appropriate focus is on the presenting symptoms and the syndrome, but it is important to realize before discharge to look at the whole picture and address cardiovascular risk as a whole, including whether they need these medications to treat concomitant medical problems, such is left ventricular dysfunction, diabetes or chronic kidney disease," he said.