Key result
In a contemporary STEMI cohort, only 22% of eligible patients were prescribed a mineralocorticoid receptor antagonist at discharge, with lower LVEF and later calendar year predicting prescription.
Why the study?
Guidelines recommend MRA use post-MI with LVEF ≤40% and heart failure or diabetes, but real-world utilization in STEMI with LV dysfunction needed evaluation.
What is the real-world utilization rate of MRAs in eligible patients with STEMI and left ventricular dysfunction?
Cohort (n=2,691)
What is the real-world utilization rate of MRAs in eligible patients with STEMI and left ventricular dysfunction?
Answers are grounded in this paper and cite their sources.
There is a significant gap in guideline-directed medical therapy post-STEMI, with only 1 in 4 eligible patients receiving an MRA within 3 months of hospitalization.
Background Guidelines recommend mineralocorticoid receptor antagonist (MRA) use in patients with left ventricular ejection fraction ≤40% following a myocardial infarction plus heart failure or diabetes mellitus, based on mortality benefit in the EPHESUS (Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study) trial. The objective of this study was to evaluate the real-world utilization of MRAs for patients with ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction. Methods and Results The prospective, population-based, Vancouver Coastal Health Authority STEMI database was linked with local outpatient cardiology records from 2007 to 2018. EPHESUS criteria were used to define post-STEMI MRA eligibility (left ventricular ejection fraction ≤40% plus clinical heart failure or diabetes mellitus, and no dialysis-dependent renal dysfunction). The primary outcome was MRA prescription among eligible patients at discharge and the secondary outcome was MRA prescription within 3 months postdischarge. Of 2691 patients with STEMI, 317 (12%) were MRA eligible, and 70 (22%) eligible patients were prescribed an MRA at discharge. Among eligible patients with no MRA at discharge, 12/126 (9.5%) with documented postdischarge follow-up were prescribed an MRA within 3 months. In multivariable analysis, left ventricular ejection fraction (odds ratio [OR], 1.55 per 5% left ventricular ejection fraction decrease; 95% CI, 1.26-1.90) and calendar year (OR, 1.23 per year, 95% CI, 1.11-1.37) were associated with MRA prescription at discharge. Other prespecified variables were not associated with MRA prescription. Conclusions In this contemporary STEMI cohort, only 1 in 4 MRA-eligible patients were prescribed an MRA within 3 months following hospitalization despite high-quality evidence for use. Novel decision-support tools are required to optimize pharmacotherapy decisions during hospitalization and follow-up to target this gap in post-STEMI care.
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Wong et al. (2021) conducted a cohort in ST-segment-elevation myocardial infarction (STEMI) with left ventricular dysfunction (n=2,691). Mineralocorticoid receptor antagonist (MRA) prescription was evaluated on MRA prescription among eligible patients at discharge. In a contemporary STEMI cohort, only 22% of eligible patients were prescribed a mineralocorticoid receptor antagonist at discharge, with lower LVEF and later calendar year predicting prescription.
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