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M 19: Adherence to Guideline on Use of Analgesics in Patients with First Myocardial Infarction Event: A Stepped-Care Approach

Poster Presenter

Myungsuk Yang

Student, Department of Pharmaceutical Industry
Chung-Ang University
Korea, Republic of

Objectives

The study aims were to assess adherence to the American Heart Association guideline on the use of non-steroidal anti-inflammatory drugs with a stepped-care approach and to compare the risk of cardiovascular events between patients treated with guideline adherence and those without.

Method

Using national health insurance sharing service cohort database, patients with first myocardial infarction between 2008 and 2011 included and guideline adherence was assessed with 2-year follow up. With propensity score matching, Kaplan-Meier curve and Cox regression analyses were conducted. Author: MyungSuk Yang1 Co-authors: SeungYeon Song2, JinUk Suh1, Hyunjun Shim1, JiHee Yun1, Eunyoung Kim1,2 Affiliation : 1 Department of Pharmaceutical Industry Management, Graduate School, Chung-Ang University, Seoul, South Korea 2 Department of Health, Social and Clinical Pharmacy, College of Pharmacy, Chung-Ang University, Seoul, South Korea

Results

Between 2008 and 2011, 1,681 patients had a first-time myocardial infarction and of this, 1,076 patients used analgesics (acetaminophen and/or narcotics, or non-steroidal anti-inflammatory drugs) for musculoskeletal discomforts. Only 20% of these patients were treated non-steroidal anti-inflammatory drugs (NSAIDs) with adherence to the guideline-recommended stepped-care approach. For analysis, guideline-concordant patients and discordant patients were propensity score matched using covariates such as age, sex, comorbidities and concurrent medications. Finally, 216 patients were included in each group. All patients were followed until either a cardiovascular event (death, MI, stroke, transient ischemic attack, embolism) whichever occurred first or up to 2 years. In the concordant group, the number of CV events was 127 and the discordant group was 142 (p=0.137). Using Kaplan-Meier methods, showed statistical significance between two groups (p=0.02). Multivariate Cox regression analysis of the concordant groups showed that an increased risk of cardiovascular event exists when treated with acetaminophen and/or narcotics (HR, Hazard Ratio, 1.15 [95% CI, Confidence Interval, 0.55-2.40]), non-selective NSAIDs (HR,1.59 [95% CI, 0.73-3.47]) and selective NSAIDs (HR,4.32 [95% CI, 0.54-34.35]) compared to no medication. In discordant group, an increased risk was also found with acetaminophen and/or narcotics (HR, 1.18 [95% CI, 0.59-2.35]), non-selective NSAIDs (HR, 2.45 [95% CI, 1.51-3.98]) and selective NSAIDs (HR, 3.54 [95% CI, 1.03-12.24]) compared with no medication. When the concordant group and the discordant group were compared, the discordant group was associated with an increased risk with acetaminophen and/or narcotics (HR,1.26 [95% CI, 0.97-1.62]), non-selective NSAIDs (HR,2.36 [95% CI, 1.75-3.18]), selective NSAIDs (HR,3.02 [95% CI, 2.29-3.99]) compared to the concordant group.

Conclusion

In this study, we analyzed the adherence to the stepped-care approach recommendations of the 2007 American Heart Association guideline when using NSAIDs in first-time myocardial infarction patients. Also, we compare the risk of cardiovascular event between guideline-concordant group and discordant group using a national health insurance sharing service cohort database in the Republic of Korea. Of first-time myocardial infarction patients with diagnosis of musculoskeletal discomforts, only 20% had received analgesic drugs with guideline-adherence. We found that the guideline-concordant group represents better prognosis compared to the discordant group and that use of acetaminophen and/or narcotics, non-selective NSAIDs and selective NSAIDs increase cardiovascular event risk from least to most. The number of cardiovascular events related with the use of selective NSAIDs are much fewer than the number related with the use of non-selective NSAIDs. The reason behind such phenomenon could be due to the stepped-care approach recommendation to use selective NSAIDs only when intolerable discomfort persists despite using other drugs, such as acetaminophen and/or narcotics and non-selective NSAIDs. In conclusion, our results suggest that increased and multidisciplinary efforts are required to increase adherence to the guideline recommendations to help prevent cardiovascular events in myocardial infarction patients when using NSAIDs.