Author + information
- Min Li1,
- Yubei Huang2,
- Xin Du3,4,
- Shenshen Li3,
- Anushka Patel5,
- Runlin Gao6,
- Jiachao Ji3 and
- Yangfeng Wu1,3,7
- 1Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, 100191, China
- 2Department of Epidemiology and Biostatistics, Tianjin Medical University Cancer Institute and Hospital, Tianjin, China
- 3The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- 4Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- 5The George Institute for Global Health, University of Sydney, Australia
- 6The Department of Cardiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, BJ
- 7Peking University Clinical Research Institute, Beijing, China
While the role of four medications (antiplatelet agents (aspirin or clopidogrel), angiotensin converting enzyme inhibitor/angiotensin receptor blocker, statin and beta-blockers) in preventing the incidence of acute coronary syndrome (ACS) is well-established, it is unclear whether these four medication benefit patients who develop ACS despite its use.
The study population was drawn from the Clinical Pathways for Acute Coronary Syndromes-Phase 2 Study. 14790 ACS patients were recruited from 75 hospitals across China. Logistic regression and propensity-score analysis were applied to assess the association between prior use of the four medications and in-hospital clinical outcomes including disease severity (type of ACS, systolic blood pressure <90 mmHg, and heart rate>=100 beats/min), complicating arrhythmia and major adverse cardiovascular events (MACEs, including all deaths, non-fatal myocardial infarction or re-infarction, and non-fatal stroke). Then, to test the hypothesis that the effect of prior use of four medications may be mediated through the effect on disease severity at presentation, multiple logistic regression was performed with additional adjusting for disease severity. The trend of risk with increase of number of the medications was tested. We also did the analysis separately for patients with and without history of cardiovascular disease to reveal if the purpose of prior use of these medications (primary or secondary prevention) modified the effects.
Among the four preventive medications, use of antiplatelet agents was most commonly reported (31.1%), while statins were least used (13.3%). The proportion of no prior use of any of the four preventive medications was 61.8%, while it is still high (46.9%) even among those with history of cardiovascular disease. Prior use of each of the four medications was significantly associated with less severity of disease (ORs ranged from 0.38 to 0.82, all P<0.05), less arrhythmia (ORs ranged from 0.45 to 0.64, all P<0.05), and reduced risk of MACEs (ORs ranged from 0.59 to 0.73, all P<0.05) during hospitalization, after adjusting for multiple confounding factors. Notably, many of the association became non-significant after further adjusting for disease severity at presentation. Multiple variable-adjusted ORs of MACEs were 0.77, 0.67, 0.48 and 0.59 respectively in patients with 1, 2, 3 and 4 medications in comparison with patients with none, and other clinical outcomes showed the same trend (P for trend < 0.05). There was no significant differences except that 95% CI were generally wider, when the association were analyzed among patients with and without history of cardiovascular disease separately.
Prior use of four preventive medications may reduce the severity of disease and in-hospital adverse outcomes in those who do develop an ACS anyway while taking these medications. The beneficial effect of prior use of these medications may be mainly mediated through increasing the likelihood of developing a less severe ACS when this doses occur.