Assessment of the effectiveness of treatment in patients after acute coronary syndrome

Aim. To assess the effectiveness of secondary drug prevention and surgical myocardial revascularization in patients with coronary artery disease (CAD) during long-term follow-up after acute coronary syndrome (ACS).

Material and methods. The study involved 400 patients with ACS discharged from the hospital in 2012-2016. The diagnosis was verified according to the European Society of Cardiology (ESC) guidelines. There were no exclusion criteria. We analyzed the data of medical records (complaints, medical history, physical examination, laboratory and instrumental data). Repeated data collection was carried out by distance survey and during a face-to-face examination during 2018. According to the clinical course of CAD, all patients were divided into 2 groups. Group 1 consisted of 151 patients with complicated course of CAD, group 2 — 249 patients with stable CAD. We analyzed drug therapy recommended at hospital discharge and taken at the time of the repeated examination. The drug names and daily dosage used for the secondary prevention of CAD were recorded. Assessment of survival without cardiovascular complications was carried out according to the Kaplan-Mayer analysis.

Results. Seven-year mortality was 22,5%. The total number of cardiovascular events was 37,7%. The main reason for the frequent complications was the insufficient secondary prevention of CAD after ACS. We found that the drugs and their dosage did not have a significant effect on survival. Statin use is associated with a paradoxical increase in the number of complications. The increased frequency of use and dosage of statins are a consequence of unfavorable course of CAD and do not have the proper preventive effect. For some groups of drugs, we observed irregular intake over the observation period. The low effectiveness of therapy is not only due to insufficient doses, but also in the frequent use of generic drugs. The significant effect of coronary angiography on the probability of cardiovascular complications compared with stenting is due to high proportion of coronary angiography use without revascularization.

Conclusion. The combination of following factors of drug therapy can explain the low effectiveness of secondary CAD prevention: low dose (26,1±2,8 mg for atorvastatin), irregular intake and common use of generic drugs (97,6% for statins), present in different ratios. The contribution of surgical treatment to reducing cardiovascular complications is lower, the more significant residual coronary artery stenosis.

1. Alnasser SMA, Huang W, Gore JM, et al. Late Consequences of Acute Coronary Syndromes: Global Registry of Acute Coronary Events (GRACE) Follow-up. Am J Med. 2015;128 (7):766-75. doi:10.1016/j.amjmed.2014.12.007.

2. Boytsov SA, Samorodskaya IV. High cardiovascular mortality in russia: are approaches to coding causes of death adequate? Kardiologiya. 2015;55 (1):47-51. (In Russ.) doi:10.18565/cardio.2015.1.47-51.

3. Boytsov SA, Zairatyants OV, Andreev EM, et al. Comparison of mortality rates from coronary heart disease among men and women over 50 years in Russia and the United States. Russ J Cardiol. 2017;6:100-7. (In Russ.) doi:10.15829/1560-4071-2017-6-100-107.

4. Puymirat E, Simon T, Cayla G, et al. Acute Myocardial Infarction Changes in Patient Characteristics, Management, and 6-Month Outcomes Over a Period of 20 Years in the FAST-MI Program (French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction) 1995 to 2015. Circulation. 2017;136:1908-19. doi:10.1161/CIRCULATIONAHA.117.030798.

5. Hammer Y, Iakobishvili Z, Hasdai D, et al. Guideline‐Recommended Therapies and Clinical Outcomes According to the Risk for Recurrent Cardiovascular Events After an Acute Coronary Syndrome. Journal of the American Heart Association. 2018;7:1-8. doi:10.1161/JAHA.118.009885.

6. Luepker RV. Falling Coronary Heart Disease Rates A Better Explanation? Circulation. 2016;133:8-11. doi:10.1161/CIRCULATIONAHA.115.019862.

7. Biswas S, Andrianopoulos N, Duffy SJ, et al. Impact of Socioeconomic Status on Clinical Outcomes in Patients With ST-Segment–Elevation Myocardial Infarction. Circulation: Cardiovascular Quality and Outcomes. 2019;12:1-10. doi:10.1161/CIRCOUTCOMES.118.004979.

8. Lichtman JH, Froelicher ES, Blumenthal JA, et al. Depression as a Risk Factor for Poor Prognosis Among Patients With Acute Coronary Syndrome: Systematic Review and Recommendations A Scientific Statement From the American Heart Association. Circulation. 2014;129(12):1350-69. doi:10.1161/cir.0000000000000019.

9. Smilowitz NR, Mahajan AM, Roe MT, et al. Mortality of Myocardial Infarction by Sex, Age, and Obstructive Coronary Artery Disease Status in the ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). Circulation: Cardiovascular Quality and Outcomes. 2017;10:1-8. doi:10.1161/CIRCOUTCOMES.116.003443.

10. Gilyarevskyi RS, Goldshmid MV, Sinitsin II. The role of cross-studies in assessing the effectiveness of drugs for the treatment of patients with heart disease. CONSILIUM MEDICUM. 2014;10:95-8. (In Russ.) http://conmed.elpub.ru/jour/article/viewFile/447/445.

11. Maksimov ML, Ermolaeva AS. Original bisoprolol and generics. Can you blindly trust generic drugs? Russian Medical Journal. 2016;12:749-52. (In Russ.) https://www.rmj.ru/archive/meditsinskoe-obozrenie-12-2016