Evidence-based ACS treatment options assessed for survival benefit
MedWire News: The use of multiple evidence-based therapies for acute coronary syndromes (ACS) is associated with diminishing returns, with coronary revascularization offering the most robust 6-month survival advantage, study results indicate.
The analysis may provide a “rational basis” for selecting among therapeutic options when compliance or cost is an issue, say the investigators writing in the journal Heart.
Derek Chew (Flinders Medical Center, Adelaide, Australia) and colleagues sought to define which guideline-advocated therapies offer the greatest benefit with respect to 6-month survival in patients hospitalized with ACS.
They conducted a nested case–control study of ACS patients enrolled in the Global Registry of Acute Coronary Events (GRACE) between April 1999 and December 2007. In all, 1716 patients who died within 6 months of hospital discharge were matched for age and gender with 3432 controls who were alive at 6 months.
All patients were assessed for the use of evidence-based, guideline-recommended ACS therapies, including both medications and coronary interventions.
Chew et al found that the likelihood of dying fell with each additional therapy used, up to a maximum of seven. Using none or one therapy as the referent, the odds ratio for 6-month mortality was 0.80, 0.74, 0.59, 0.51, 0.40, 0.27, and 0.31 for two, three, four, five, six, seven, and eight therapies, respectively.
After adjusting for clinical and regional factors, percutaneous coronary intervention or coronary artery bypass graft surgery were associated with the most substantial survival advantage, report the authors. In terms of pharmacotherapy, use of clopidogrel and statins offered the greatest survival advantage.
Up to 31.9% and 9.7% of deaths by 6 months may be prevented with more complete use of revascularization and statin therapy, they write.
When analyzed collectively, the use of all guideline-recommended therapies was associated with a marked reduction in 6-month mortality (odds ratio=0.29). Little incremental gain was observed with the use of more than six such therapies, however.
“With the expanding evidence base provided by clinical trials, the number of therapies and treatment strategies advocated by expert clinical guidelines can only increase,” the authors conclude.
“At a clinical level, being able to independently value these therapies may provide the rationale for choosing between treatments when a choice must be made, either for reasons of cost or compliance.”
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By Joanna Lyford