Prof. Adam Timmis
Adam Timmis(United Kingdom)
List of Authors: Boggon R, van Staa TP, Timmis A, Hemingway H, Ray KK, Begg A, Emmas C, Fox KAA
Aims: Adherence to evidence-based treatments and its consequences after acute myocardial infarction are poorly defined. We examined the extent to which clopidogrel treatment initiated in hospital is continued in primary care; the factors predictive of clopidogrel discontinuation and the hazard of death or recurrent myocardial infarction (MI). Methods & Results: We linked the Myocardial-Ischaemia-National-Audit-Project registry and the General-Practice-Research-Database to examine adherence to clopidogrel in primary care among patients discharged from hospital after MI (2003-2009). Hospital Episode Statistics and national mortality data were linked, documenting all-cause mortality and non-fatal MI. Of the 7,543 linked patients, 4,650 were prescribed clopidogrel in primary care within three months of discharge. The adjusted odds of still being prescribed clopidogrel at 12 months were similar following nSTEMI 53%(95%CI, 51-55%) and STEMI 54%(95%CI, 52-56%), but contrast with statins: nSTEMI 84%(95%CI, 82-85%), STEMI 89%(95%CI 87-90%). Discontinuation within 12 months was more frequent in older patients (>80yrs versus 40-49yrs, adjusted hazard ratio (HR) 1.50 (95%CI,1.15-1.94) and with bleeding events (HR 1.34 (95%CI 1.03-1.73). 18.15 patients per 100 person/years (95%CI 16.83–19.58) died or experienced non-fatal MI in the first year following discharge. In patients who discontinued clopidogrel within 12 months the adjusted hazard ratio for death or non-fatal MI was 1.45 (95%CI, 1.22-1.73) compared to untreated patients, and 2.62 (95%CI, 2.17-3.17) compared to patients persisting with clopidogrel treatment. Conclusion: This is the first study to use linked registries to determine persistence of clopidogrel treatment after MI in primary care. It demonstrates that discontinuation is common and associated with adverse outcomes.
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