Attaining all four guideline-directed medical therapy goals at baseline was associated with a 16% absolute reduction in cardiovascular death or myocardial infarction compared with no goals attained.
Observational (n=5,179)
Yes
Absolute Event Rate: 8.7% vs 24.5%
Absolute Risk Reduction: 16%
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.
Maron et al. (Mon,) conducted a observational in chronic coronary disease (CCD) (n=5,179). Attainment of all four guideline-directed medical therapy (GDMT) goals vs. Attainment of no GDMT goals was evaluated on cardiovascular death or myocardial infarction (CVD/MI). Attaining all four guideline-directed medical therapy goals at baseline was associated with a 16% absolute reduction in cardiovascular death or myocardial infarction compared with no goals attained.