Key result
Attaining all four guideline-directed medical therapy goals at baseline and maintaining them was associated with an absolute 15.9% reduction in cardiovascular death or myocardial infarction compared to attaining no goals.
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Why the study?
The relative importance of specific guideline-directed medical therapy goals and the timing of their attainment on cardiovascular events in patients with chronic coronary disease was uncertain.
Does the attainment of guideline-directed medical therapy goals reduce cardiovascular death or myocardial infarction in patients with chronic coronary disease?
Observational (n=5,179)
Yes
Does the attainment of guideline-directed medical therapy goals reduce cardiovascular death or myocardial infarction in patients with chronic coronary disease?
Answers are grounded in this paper and cite their sources.
Early attainment and maintenance of multiple guideline-directed medical therapy goals, particularly systolic blood pressure control, is associated with a substantial reduction in cardiovascular events in patients with chronic coronary disease.
BACKGROUND: Guideline-directed medical therapy (GDMT) with multiple risk factor goals is recommended for patients with chronic coronary disease (CCD), yet achieving all GDMT goals is uncommon. The relative importance of these goals and timing of their attainment on cardiovascular events is uncertain. OBJECTIVES: To describe the relationship between achieving specific GDMT goals, when they are achieved, and clinical outcomes. METHODS: This was an observational study of participants with CCD in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches). The primary outcome was cardiovascular death or myocardial infarction (CVD/MI). GDMT goals were systolic blood pressure (SBP) <130 mmHg, low-density lipoprotein cholesterol (LDL-C) <70 mg/dL, not smoking, and antiplatelet therapy. Frequency of GDMT goals met at baseline and during follow-up is described. Bayesian joint modeling for longitudinal goal status and time-to-event analyses characterized the relative importance of specific GDMT goal attainment and timing with CVD/MI. RESULTS: All 5,179 ISCHEMIA participants were included. Among 4,914 participants with complete data on all four GDMT goals at baseline, 386 (9%), 2,073 (42%), 1,843 (38%), and 612 (12%) met 0–1, 2, 3, and 4 GDMT goals, respectively. The 4-year cumulative event rate for CVD/MI was highest for participants who attained no GDMT goals (24.5%, 95% credible interval (CrI): 13.5, 42.2%) and lowest for those who attained all goals at baseline and remained at goal during follow-up (8.7%, 95% CrI: 6.7, 10.9%). SBP goal attainment was associated with a significant absolute event reduction in CVD/MI (−5.1%, 95% CrI: −11.3, −1.0%), followed by antiplatelet therapy (−11.2%, 95% CrI: −29.1, 0.8%), achieving LDL-C <70 mg/dL (−2.0%, 95% CrI: −6.0, 2.4%) and not smoking (−1.7%, 95% CrI: −9.3, 4.2%). 10 mmHg lower SBP during follow-up was associated with 10% relative risk reduction of CVD/MI (RR=0.90, 95% CrI: 0.82, 0.98), after adjusting for other GDMT goals and baseline characteristics. CONCLUSIONS: Among participants with CCD, early attainment and maintenance of GDMT goals, especially SBP, were associated with fewer cardiovascular events. Compared with no GDMT goals at target, having all four GDMT goals at target at baseline was associated with an absolute 16% fewer cardiovascular deaths and myocardial infarctions.
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Maron et al. (2025) conducted an observational in Chronic coronary disease (CCD) with moderate or severe ischemia (n=5,179). Attainment of all 4 guideline-directed medical therapy (GDMT) goals (SBP <130 mmHg, LDL-C <70 mg/dL, not smoking, antiplatelet therapy) vs. Attainment of 0 GDMT goals was evaluated on Cardiovascular death or myocardial infarction (CVD/MI) at 4 years (Absolute event reduction 15.9%, 95% CI 3.5-34.6). Attaining all four guideline-directed medical therapy goals at baseline and maintaining them was associated with an absolute 15.9% reduction in cardiovascular death or myocardial infarction compared to attaining no goals.
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