Cumulative Adherence to Secondary Prevention Guidelines and Mortality After Acute Myocardial Infarction

Abstract

Background The survival benefit associated with cumulative adherence to multiple clinical and lifestyle‐related guideline recommendations for secondary prevention after acute myocardial infarction ( AMI ) is not well established. Methods and Results We examined adults with AMI (mean age 68 years; 64% men) surviving at least 30 (N=25 778) or 90  (N=24 200) days after discharge in a large integrated healthcare system in Northern California from 2008 to 2014. The association between all‐cause death and adherence to 6 or 7 secondary prevention guideline recommendations including medical treatment (prescriptions for β‐blockers, renin‐angiotensin‐aldosterone system inhibitors, lipid medications, and antiplatelet medications), risk factor control (blood pressure <140/90 mm Hg and low‐density lipoprotein cholesterol <100 mg/dL), and lifestyle approaches (not smoking) at 30 or 90 days after AMI was evaluated with Cox proportional hazard models. To allow patients time to achieve low‐density lipoprotein cholesterol <100 mg/dL, this metric was examined only among those alive 90 days after AMI . Overall guideline adherence was high (35% and 34% met 5 or 6 guidelines at 30 days; and 31% and 23% met 6 or 7 at 90 days, respectively). Greater guideline adherence was independently associated with lower mortality ( hazard ratio, 0.57 [95% CI, 0.49–0.66] for those meeting 7 and hazard ratio, 0.69 [95% CI, 0.61–0.78] for those meeting 6 guidelines versus 0 to 3 guidelines in 90‐day models, with similar results in the 30‐day models), with significantly lower mortality per each additional guideline recommendation achieved. Conclusions In a large community‐based population, cumulative adherence to guideline‐recommended medical therapy, risk factor control, and lifestyle changes after AMI was associated with improved long‐term survival. Full adherence was associated with the greatest survival benefit.