Key result
Four-class GDMT at discharge vs 0–2 classes after STEMI was associated with lower 5-year risk of cardiovascular death, stroke, or MI (adjusted HR 0.49; 95% CI 0.33–0.72).
Why the study?
Implementation and long-term persistence of guideline-directed medical therapy following STEMI remain suboptimal, prompting this assessment of four-class GDMT persistence and its association with outcomes.
Does higher guideline-directed medical therapy class (3 or 4 drug classes vs 0–2) reduce the risk of the composite of cardiovascular death, stroke, or myocardial infarction in patients undergoing PCI for STEMI?
Observational (n=7,913)
Yes
Does higher guideline-directed medical therapy class (3 or 4 drug classes vs 0–2) reduce the risk of the composite of cardiovascular death, stroke, or myocardial infarction in patients undergoing PCI for STEMI?
Although over two-thirds of STEMI patients undergoing PCI are discharged on all four classes of GDMT, long-term persistence declines substantially over 5 years, while maintaining 3 or 4 GDMT classes is associated with a roughly 50% lower risk of major adverse cardiovascular events.
Answers are grounded in this paper and cite their sources.
Sustained GDMT adherence after STEMI warrants targeted clinical strategies; extends pooled RCT evidence linking higher long-term use to lower CV risk.
Background Implementation and long-term persistence of guideline-directed medical therapy (GDMT) following ST-segment elevation myocardial infarction (STEMI) remain suboptimal. We assessed the implementation and persistence of four-class GDMT after STEMI and its association with outcomes. Methods We performed a patient-level pooled analysis of three randomised trials of patients undergoing percutaneous coronary intervention for STEMI. GDMT was defined by the number of drug classes prescribed (0–4). External validation was conducted using a real-world PCI registry. Findings The study included 2270 patients from the randomised trials and 5643 from a real-world PCI registry. More than two-thirds of patients received all four GDMT classes at discharge (ranging from 66.9% [398/595] to 83.5% [339/406]), but this proportion declined over 5 years (ranging from 40.5% [408/1008] to 53.1% [276/520]). In exploratory analyses, higher GDMT class at discharge was associated with a lower risk of the composite of cardiovascular death, stroke, or myocardial infarction at 5 years (adjusted HR [95% CI] for class 4 versus 0–2: 0.49 [0.33–0.72]; class 3 versus 0–2: 0.49 [0.28–0.85]). In a time-dependent analysis, higher GDMT class during follow-up was associated with a lower risk of the composite outcome (adjusted IRR [95% CI] for class 4 versus 0–2: 0.71 [0.52–0.95]; class 3 versus 0–2: 0.59 [0.41–0.86]). Similar longitudinal patterns were observed in the real-world PCI registry. Interpretation Although the majority of patients received all four GDMT classes at discharge after STEMI, this proportion declined during long-term follow-up. In exploratory analyses, higher GDMT class was associated with a lower risk of cardiovascular events. Funding No specific funding was received for the present study. Funding for the individual trials and registry is reported in the Acknowledgements.
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Tomii et al. (2026) conducted an observational in ST-segment elevation myocardial infarction (STEMI) (n=7,913). Four-class guideline-directed medical therapy (GDMT) vs. 0–2 GDMT drug classes was evaluated on Composite of cardiovascular death, stroke, or myocardial infarction at 5 years (HR 0.49, 95% CI 0.33-0.72). Four-class GDMT at discharge vs 0–2 classes after STEMI was associated with lower 5-year risk of cardiovascular death, stroke, or MI (adjusted HR 0.49; 95% CI 0.33–0.72).
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