What is the clinical evidence from this study?

Study design: Cohort. Population: Coronary artery disease after coronary revascularization (n=5544). Intervention: Statin use vs. No statin use. Primary outcome: Composite of major adverse cardiac and cerebrovascular events (MACCE) (HR 0.74, 95% CI 0.64-0.85, p=<0.0001).

May 2, 2019Open Access

The effects of secondary prevention after coronary revascularization in Taiwan

Q: What are the key findings of this study?

Statin use was an independent protective factor against major adverse cardiac and cerebrovascular events in patients after percutaneous coronary intervention (HR 0.74) and coronary artery bypass grafting (HR 0.76).

WFWen-Han FengKaohsiung Medical University Chung-Ho Memorial Hospital CCChun‐Yuan ChuInterventional / Structural Cardiology PHPo‐Chao HsuInterventional Cardiology

Key Result

Statin use was an independent protective factor against major adverse cardiac and cerebrovascular events in patients after percutaneous coronary intervention (HR 0.74) and coronary artery bypass grafting (HR 0.76).

Study Design

Type

Cohort (n=5,544)

Structured PICO

Does secondary prevention therapy with ACC/AHA class I medications improve outcomes in patients after coronary revascularization?

Population

5,544 patients who underwent coronary artery bypass grafting or percutaneous coronary intervention in Taiwan between 2004 and 2009, followed for up to 6 years.

Exposure

Secondary prevention therapy (ACC/AHA class I medications: antiplatelet agent, β-blocker, renin-angiotensin system blocker, or statin)

Outcome

Composite of major adverse cardiac and cerebrovascular eventscomposite

Guideline-directed secondary prevention medications are underutilized in post-revascularization patients in Taiwan, particularly following CABG, despite statin therapy demonstrating a protective effect against major adverse events.

Main Result

Hazard Ratio: 0.74 (95% CI 0.64–0.85)

p-value: p=<0.0001

Limitations

Lacked sufficient detailed clinical data to explore reasons why certain medications were not prescribed (e.g., serum creatinine, left ventricular function, LDL level).
Data only showed drugs prescribed by doctors, but actual patient adherence remains unknown.
Underlying diseases were determined based on ICD codes, which may underestimate comorbidities.
National insurance reimbursement criteria may limit medications physicians can prescribe.
Potential survivor bias while assessing medication usage and hazards of cardiac outcomes.
National health insurance only allowed 9-month dual antiplatelet treatment.

Abstract

BACKGROUND: Secondary prevention therapy for patients with coronary artery disease using an antiplatelet agent, β-blocker, renin-angiotensin system blocker (RASB), or statin plays an important role in the reduction of coronary events after coronary artery bypass grafting (CABG) surgery or percutaneous coronary intervention (PCI). We analyzed the status and effects of secondary prevention after coronary revascularization in Taiwan. METHODS: This national population-based cohort study was conducted by analyzing the Longitudinal Health Insurance Database 2000 from the National Health Insurance Research Database of Taiwan. Patients who underwent CABG or PCI from 2004 to 2009 were included in the analysis. The baseline characteristics of the patients and ACC/AHA class I medication use at 12 months were analyzed. The primary endpoints were a composite of major adverse cardiac and cerebrovascular events. RESULTS: A total of 5544 patients comprising 895 CABG and 4649 PCI patients were evaluated. CABG patients had more comorbidities and a higher rate of major adverse event during the follow-up period. However, use of antiplatelet agents and RASB at 12 months was significantly lower in CABG patients than in PCI patients (44.2% vs. 50.9% and 38.6% vs. 48.9%, both p < 0.01). Age, diabetes, and chronic kidney disease were independent risk factors while statin use was a protective factor for the primary endpoints in both PCI and CABG groups. CONCLUSION: There is still much room to improve class I medication use in secondary prevention for patients after revascularization in Taiwan. Statin could be an effective treatment to improve the outcomes.

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