Secondary Prevention: A Responsibility We Should Not Delegate

After coronary angioplasty, the use of drugs whose efficacy for the reduction of major events has been proven declines over time, which is associated with worse patient prognosis.

Sometimes, without meaning to, we convey to patients the idea that, once the stent has been implanted, the artery is “cured” or that the only potential future problem is restenosis. This sense of being “cured” is obviously false, but, truth be told, no study had followed patients after angioplasty in the long term so as to prove this notion with concrete numbers.

This study, recently published in Circ Cardiovasc Qual Outcomes, addressed secondary prevention in order to shed some light on patient treatment adherence after coronary angioplasty and its impact on prognosis.

Researchers identified 57,900 patients who underwent angioplasty between 2005 and 2014, and studied their use of statins, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and P2Y12 inhibitors. The use of such drugs was registered at discharge, 6 months, 1 year, 3 years, and 5 years after angioplasty.

Read also: ESC 2018 | ARRIVE: Aspirin in the Eye of the Storm of Primary Prevention.

At discharge, slightly over half the patients (58.3%) left with all medications. Use of statins, β-blockers, and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers fell from 89%, 84.9%, and 72.2% on discharge, respectively, to 72.7%, 67.9%, and 57.9%, respectively, at 5 years.

Prescription of P2Y12 inhibitors fell from 96.5% on discharge to 28.3% at 5 years, with a clear decline 1 year after the procedure.

The use of each class of medication and their combination was associated with a significant reduction in major events (death, infarction, stroke, or repeat revascularization).

Read also: Aspirin in Primary Prevention: Another “Trendy” Topic in Publications.

Among all drugs, statins generated the largest impact (hazard ratio [HR]: 0.77; 95% confidence interval [CI]: 0.75–0.79; p < 0.0001) followed by P2Y12 inhibitors (HR: 0.82; 95% CI: 0.79–0.85; p < 0.0001).

Another highlight is the high rate of repeat revascularization in patients who continued using all drugs up to 5 years. This could be explained in several ways: 1) patients who continued using all drugs are those who most frequently had checkups, which resulted in the detection of many clinically silent restenosis, and 2) the group of patients who continued using all drugs could also reflect a group with more complex anatomy and multivessel disease.

Such evidence is retrospective, and the study has multiple methodological limitations, but it cannot go unnoticed. Secondary prevention is the responsibility of interventional cardiologists as much as of clinical cardiologists.

2019-12-24-10-1161-CIRCOUTCOMES-118-005455

Original title: Medical Therapy Utilization and Long-Term Outcomes Following Percutaneous Coronary Intervention. Five-Year Results From the Veterans Affairs Clinical Assessment, Reporting, and Tracking System Program.

Reference: Joe X. Xie et al. Circ Cardiovasc Qual Outcomes. 2019;12:e005455.

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