Cardiovascular disease remains the leading cause of death worldwide.1,2 Advances in management strategies have, however, reduced population-level mortality rates for certain cardiovascular conditions over the past several decades, such as for coronary artery disease.3 As part of these advances, the use of effective therapies such as antiplatelet therapies (APT) has increased substantially over time in higher-income countries, with guidelines now recommending APT for secondary prevention of cardiovascular events in patients with conditions such as myocardial infarction, stroke, and peripheral arterial disease.4-6
Barriers for use of APT have included concerns about medication burden, medication interactions that may increase bleeding risks, and cost and access to medications. However, as of 2011, NHS Scotland removed any potential issues around the cost of APT, as all prescription medicines are now free to the patient. To clarify the quality gap for use of APT for secondary prevention of cardiovascular disease in this population, Thalmann et al. recently looked at uptake of these APTs across patients discharged from an NHS Scotland facility with a primary diagnosis of a cardiovascular event from 2009-2017.7
After excluding patients with underlying atrial fibrillation who required antithrombotic therapy, the authors found ongoing disparities in uptake of APT by age, gender, and diagnosis. These disparities were most pronounced in female patients discharged with a diagnosis other than myocardial infarction or stroke, who had 31% lower odds of receiving APT than male patients, and in patients with previous mental health hospitalizations, who had 45% lower odds. Differences were also noted by deprivation index (5% lower odds in the most deprived quintile relative to the least deprived) and in those aged less than 50 or greater than 70 years. Furthermore, patients with myocardial infarction or stroke who had two or more comorbidities had significantly lower odds of initiating APT, even though these patients likely have the highest risk of future cardiovascular events. Finally, in patients who did receive APT, almost one-quarter of patients discontinued therapy in the ensuing years (half of whom discontinued the medication within 1.5 years). Even with one-third of the patients who discontinued the medication eventually resuming them, approximately 20% of patient-years studied were not covered by APT. Overall, the authors estimate closing these quality gaps may have prevented 25% of the events in the patient-years without APT and 5% of all cardiovascular events in the population.
Possible reasons for the quality gap are many. From the ordering standpoint, some patients will have allergies or intolerances to the medications. Non-myocardial infarction diagnoses, especially those related to peripheral arterial disease, may be considered less severe or these patients may have fewer procedural interventions that prompt clinicians to consider prescriptions. However, as noted by the authors, even in patients with myocardial infarction who underwent percutaneous intervention between 2015-17, 97% of whom received APT, one-third of patients did not receive guideline-recommended dual APT for any period. Thus, a substantial portion of the gap relates to not discharging patients who would benefit from APT on the full slate of appropriate medications. Potential targets for improvement in ordering APT therefore include standardising discharge processes for those with affected diagnoses, post-procedural pathways with automatic medication ordering and multidisciplinary discharge medication reconciliation.
From the patient standpoint, the medication burden for secondary prevention of cardiovascular events can be high. In someone not previously taking any cardiovascular medications, discharge post-myocardial infarction and percutaneous intervention would necessitate at least five new recommended medications. For these and other reasons, some patients inevitably will not fill their APT prescriptions. Some patients discharged without APT prescriptions or who did not fill the medications may be identified in clinical follow-up or post-discharge medication reconciliation, especially if providers might be prompted to consider the need for APT based on the recent diagnosis of a cardiovascular event or hospitalisation. Discontinuations, on the other hand, likely have more potential etiologies, including patient medication ‘fatigue’, bleeding events that lead to transitions in the risk/benefit assessments for individual patients, transitions in goals of care, inadequate follow-up, downstream focus on other clinical issues, deprioritization of APT after several years have passed, and/or errors related to restarting the medication after temporary holding for procedures. Given the breadth of possible reasons for not receiving APT and discontinuation, building systems-level responses to improve receipt and adherence is daunting.
Ultimately, improvements in electronic health record tools may be needed to facilitate identifying patients falling into these types of quality gaps. Currently, many health systems can track statin use in patients with known cardiovascular disease in primary care, and similar functions may be necessary for antiplatelet agents. As the authors note from their previous work, however, there remain significant similar disparities in statin use in Scotland.8 Thus, tools highlighting these gaps directly at the point-of-care and smoothly supporting their ordering within existing workflows may be necessary to maximize shared decision-making and prescriptions on the clinician front and restarting meds more quickly where they have lapsed. As therapies for chronic conditions continue to evolve, our strategies for ensuring the right patients receive the right treatments for the right (often extended) period of time will also need to adapt to continue improving population health.
1. World Health Statistics 2023: a visual summary. https://www.who.int/data/stories/world-health-statistics-2023-a-visual-summary/.
2. Tsao CW, Aday AW, Almarzooq ZI, et al.; on behalf of the American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2022 update: a report from the American Heart Association]. Circulation. doi: 10.1161/CIR.0000000000001052.
3. Nabel EG, Braunwald E. A tale of coronary artery disease and myocardial infarction. N Engl J Med. 2012 Jan 5;366(1):54-63. doi: 10.1056/NEJMra1112570. Erratum in: N Engl J Med. 2012 Mar 8;366(10):970. PMID: 22216842.N Engl J Med 2012; 366:54-63.
4. Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022 Jan;145(3):e18-e114. DOI: 10.1161/cir.0000000000001038. PMID: 34882435.
5. Kleindorfer DO, Towfighi A, Chaturvedi S, et al. 2021 Guideline for the Prevention of Stroke in Patients With Stroke and Transient Ischemic Attack: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2021 Jul;52(7):e364-e467. doi: 10.1161/STR.0000000000000375.
6. Aboyans V, Ricco JB, Bartelink MEL, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018 Mar 1;39(9):763-816. doi: 10.1093/eurheartj/ehx095. PMID: 28886620.
7. Thalmann I, Preiss D, Schlackow I, et al. Quality of care for secondary cardiovascular disease prevention in 2009–2017: population-wide cohort study of antiplatelet therapy use in Scotland. BMJ Quality & Safety Published Online First: 29 September 2023. doi: 10.1136/bmjqs-2023-016520.
8. Thalmann I, Preiss D, Schlackow I, et al. Population-wide cohort study of Statin use for the secondary cardiovascular disease prevention in Scotland in 2009–2017. Heart 2023;109:388–95.