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Secondary Prevention Medication Use and Outcomes in Frail Older Adults After AMI
Study Questions:
In frail, elderly post acute myocardial infarction (AMI) patients, does increasing use of secondary prevention guideline-directed medications improve mortality, rehospitalization, and functional decline?
Methods:
This is a retrospective, new-user cohort analysis of long-stay nursing home residents ≥65 years old who were hospitalized for AMI (no prior AMI history) who had not previously taken beta-blockers, statins, antiplatelet therapy, or renin-angiotensin-aldosterone inhibitor medications and were admitted back to a nursing home after discharge from hospital between May 1, 2007 and December 31, 2010. If patients had extremely poor functional status prior to AMI, they were excluded due to unlikelihood of further functional decline. Three levels of secondary prevention medications (beta-blockers, statins, antiplatelet therapy, or renin-angiotensin-aldosterone inhibitors) were used. The groups included 1, 2, and 3-4 medications used. Those on zero medications were not included because the group was considered sicker and less likely to receive benefit from the medications.
Results:
The majority of the cohort was female (n = 3,269; 68%) and white race (n = 4,014; 84%), with a mean age of 84 years. Most common chronic conditions included hypertension (n = 2,706; 56.5%) and heart failure (n = 2,437; 50.9%). Moderate to severe cognitive impairment was seen in about 50% (n = 2,373) of the cohort, and 74% (n = 3,542) needed extensive or greater assistance with activities of daily living. The nursing home residents were taking an average of 11 medications. Of the 4,787 post-AMI nursing home residents, 1,825 (38.1%) received 1 medication, 1,572 (32.8%) received 2 medications, and 1,390 (29%) received 3-4 medications. A decrease in mortality was found in patients who received 3-4 medications compared with those who received 1 medication post-AMI (odds ratio [OR] 0.74; 95% confidence interval [CI], 0.57-0.97); however, there was not a significant difference in functional decline (OR 1.12; 95% CI, 0.89-1.40) or rehospitalization (OR 0.97; 95% CI, 0.80-1.17). There was not a significant decrease in mortality (OR 0.98; 95% CI, 0.79-1.22), functional decline (OR 1.04; 95% CI, 0.85-1.28), or rehospitalization (OR 1.00; 95% CI, 0.85-1.19) for those prescribed 2 medications instead of 1 medication. An association with more medications leading to functional decline was found when antiplatelet medications were removed from analysis for 2 medications (OR 1.27; 95% CI, 1.07-1.53) and for 3 medications (OR 1.30; 95% CI, 1.03-1.63).
Conclusions:
In frail, elderly adults post-AMI, use of more secondary prevention medications decreased mortality. The use was not associated with a decrease in rehospitalization.
Perspective:
A decrease in mortality was found with the use of more post-AMI secondary prevention medications in elderly frail adults; research is needed to determine the association between use of more medications and functional decline.
Keywords: Secondary Prevention, Frail Elderly, Myocardial Infarction, Nursing Homes, Activities of Daily Living, Cognitive Dysfunction, Neurocognitive Disorders, Renin, Aldosterone, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Angiotensins, Adrenergic beta-Antagonists, Mineralocorticoid Receptor Antagonists, Platelet Aggregation Inhibitors
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