Guideline-based therapy may be underutilized following PCI, CABG

Rates of optimal care following PCI or CABG surgery were uncomfortably low, according to a study published online Feb. 24 in Circulation. The analysis revealed that by five years of follow-up, only around a third of patients in either group were receiving guideline-based therapies.

Researchers using the data from the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) study defined “optimal care” as a combination of at least one statin, antiplatelet drug, beta-blocker and ACE inhibitor/ARB. SYNTAX was a randomized, multicenter clinical trial that enrolled patients with complex coronary artery disease. Javaid Iqbal, MRCP, PhD, of the Thoraxcenter at the Erasmus Medical Center in Rotterdam, the Netherlands, and colleagues reviewed drug history data collected at discharge, one month, six months, one year, three years, and five years postsurgical follow-up.

They found that optimal care was initially 50.2 percent among PCI patients, while for CABG, only 31.2 percent. At five years, CABG rates for optimal care were still low but had increased slightly (35.7 percent) while rates for PCI patients had dropped dramatically (39.6 percent).

Patients who received optimal care had significant reductions in risk for mortality or for death, MI or stroke (hazard ratio 0.64 and 0.73, respectively). Optimal care, they noted, was underused but an independent predictor of survival. This is in line with previous studies.

This study, Iqbal et al noted, “reinforces the importance of OMT [optimal medical therapy] use for patients with complex CAD [coronary artery disease] undergoing revascularization.”

Jennifer A. Rymer, MD, of the Duke University Medical Center in Durham, N.C., and colleagues wrote in an editorial that the study “should give us all a sense of discomfort and encourage us to redouble our efforts to ensure that we are using optimal medical therapy as we know it today.” Adherence to optimal therapy in previous reports also reduced mortality by a third, Rymer et al noted. While the data from Iqbal et al confirmed that optimal therapy significantly improved outcomes, the concern for the general lack of adherence to optimal care was equally significant, as only a third of patients were receiving optimal care by five years, according to Iqbal et al’s findings.

“The importance of OMT should be emphasized to patients at each clinical encounter to improve compliance,” Iqbal et al wrote. They called for more research to clarify why optimal care was underutilized and to develop interventions to improve use and adherence.