Pharmacotherapy after myocardial infarctionPharmacotherapy after myocardial infarctionPharmacotherapy after myocardial infarctionPharmacotherapy after myocardial infarction
The reality of coronary prevention in BrnoThe reality of coronary prevention in Brno,,or else Is pharmacotherapy after myocardial infaction sufficientor else Is pharmacotherapy after myocardial infaction sufficient..
The reality of coronary prevention in BrnoThe reality of coronary prevention in Brno,,or else Is pharmacotherapy after myocardial infaction sufficientor else Is pharmacotherapy after myocardial infaction sufficient..
REPERFUSION
PTCA
Direct PCI for all STEMI
PTCA
60/1,000,000 = 1992
624/1,000,000 = 1998
1,220/1,000,000 = 2006
20x
PTCA
60/1,000,000 = 1992
624/1,000,000 = 1998
1,220/1,000,000 = 2006
2,250/1,000,000 = 2009
37x
STENT
5/1 000 000 = 1992449/1 000 000 = 1998
1 082/1 000 000 = 2007
200x
STENT
5/1 000 000 = 1992449/1 000 000 = 1998
1 082/1 000 000 = 20072 850/1 000 000 = 2009
570x
REMODELATION REPERFUSION
RETHROMBOSIS RESTENOSIS 4R
Beta blockadeRAAS blockade
Statins Antiaggregation
Registry Brno 2Registry Brno 2Registry Brno 2Registry Brno 2
Methods
Collection of data on patients with history of myocardial infarction > 1 month.
Outpatient follow-up in University Hospital Brno from 1 Sept. 2009 to 31 Dec. 2009.
Brno 2 registry of patient post myocardial infarction
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
23,5%
76,5%
850 pts - age and gender
Number %
Total 850
Gender M (male) 650 76.5%
F (female) 200 23.5%
Age70 years or
younger576 68.6%
over 70 years
264 31.4%
Age – mean (SD);median (5-95%)
64 (10.8); 64 (46-82)
0,5 1,0
3,3
5,5
8,8
15,7
19,4
14,313,5
11,4
5,1
1,20,2
0
2
4
6
8
10
12
14
16
18
20
Age (years)
% o
f p
ati
en
ts
Age (category)
31,4%
68,6%
70 years or younger
over 70 years
Gender
Male Female
N = 850
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Number of myocardial infarctions and age at the first infarction
Total Male Female70 years or
youngerover 70 years
Number of MIs:
1 x MI 87.8% 87.5% 88.5% 90.3% 83.0%
2 x MI 9.5% 9.5% 9.5% 8.0% 12.1%
more than 2 x MI 2.7% 2.9% 2.0% 1.7% 4.9%
0,1 0,10,7
2,2
5,8
9,3
12,6
19,6
16,7
13,4
10,2
6,9
1,9
0,4
0
2
4
6
8
10
12
14
16
18
20
Age at time of first MI (years)
% o
f p
ati
en
ts
N = 850
1st MITotal 60.5 yearsMen 59.0 yearsWomen 65.5 years
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Blood pressure
39,9%
40,9%
19,2%
less than 130/80 130/80 to 140/90 more than 140/90
Total (N=850)
44,5%
36,5%
19,0%
38,5%
42,3%
19,2%
42,0%
38,6%
19,3%
38,5%
42,4%
19,1%
Men (N=650)
Women (N=200)
70 years or younger (N=576)
over 70 years (N=264)
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Blood pressure categories
12,8
12,9
12,5
12,8
12,5
27,4
28,2
25,0
28,6
25,0
19,9
20,5
18
20
20,5
8,7
8,5
9,5
8
10,6
4
4
4
4,3
3
19,6
18,9
22
17,2
24,6
6,6
6,2
8
8
3
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Total (N=850)
Men (N=650)
Women (N=200)
70 yrs and younger (N=604)
over 70 years (N=264)
Optimal BP Normal BP High normal BP
HT 1st degree
HT 2nd degree
HT isol. diastolic
HT isol. systolic
HT 3rd degree
.
* significant difference at level 0.05
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Blood pressure
N = 850
mm
Hg
75%
Median
25%
95%
5%
BP - systole
mm
Hg
BP - diastole
over 70 years
70 years or younger
FemaleMaleTotal
70 years or
younger
70 years or
younger
Over 70 years Over 70 yearsTotal Men Women Total Men Women
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Heart rate
N = 850
75%
Median
25%
95%
5%
Pulse (per minute)
over 70 years
70 years or younger
FemaleMaleTotal
# significant difference at level <0.001
# 70 years or
younger
Over 70 yearsTotal Men Women*
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Cholesterol
27,5%
17,6%
54,9%
less than 4.5 mmol/l
4.5 to 5 mmol/l more than 5 mmol/l
35,6%
16,0%
48,4%
25,0%
18,1%
56,9%
30,4%
16,9%
52,7%
20,6%
19,3%60,1%
****
* significant difference at level 0.05** significant difference at level 0.01
Total (N=850)
Men (N=650)
Women (N=200)
70 years or younger (N=576)
over 70 years (N=264)
BP < 140/90 mmHg – 60.1%ISH – 19.6%
Cholesterol < 5 mmol/l - 72.5%
Brno 2 Achievement of target values
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Medication
ACEI or ARB
only ACEI
only ARB
ACEI and ARB
Betablocker
Statins
ASA or Clop.
only ASA
only Clop.
ASA and Clop.
93,1
76,3
16,2
0,6
91,7
93,1
94,9
76,6
0,0
18,3
0 50 100
89,4
65,0
23,6
0,5
91,0
89,4
91,0
74,0
0,5
16,5
0 50 100
92,3
75,0
16,9
0,3
93,1
94,8
95,8
74,8
0,0
21,0
0 50 100 150
91,7
71,2
19,3
1,1
87,8
86,7
89,8
78,0
0,4
11,4
0 50 100
Total (N=850) Men (N=650) Women (N=200) 70 yrs or younger (N=576)
over 70 years (N=264)
92,2
73,6
17,9
0,6
91,5
92,6
94,0
76,0
0,1
17,9
0 50 100
RAAS Betablockers Statins Antiaggregation
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Medication – drug combinations
75,8 77,769,5
81,1
63,6
19,6 18,5
23,5
15,5
29,2
3,5 3,2 52,4
6,1
0%
20%
40%
60%
80%
100%
Celkem Muži Ženy do 70 let nad 70 let
All groups Triple combination Double combination 1 group of drugs
Antiaggregation - 0.5%
RAAS - 0.2%
Statins - 0.2%
BB-Antiaggregation - 1.1%
BB-Statins - 0.2%
RAAS-Antiaggregation - 0.9%
RAAS-BB - 0.2%
RAAS-Statins - 0.7%
Statins-Antiaggregation - 0.4%
BB-Statins-Antiaggregation - 5.4%
RAAS-BB-Antiaggregation - 4.5%
RAAS-BB-Statins - 4.2%
RAAS-Statins-Antiaggregation - 5.5%
N = 850
low intermediate high
Perindopril < 2.5 2.5 – 9.9 > 10
Ramipril < 2.5 2.5 – 9.9 > 10
Trandolapril < 0.5 0.6 – 3.9 > 4
Brno 2 ACE inhibitors
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
ACEI dosing
ACEI
(N= 631)
Perindropril
(N= 271)
Ramipril
(N= 240)
Trandolapril
(N= 51)
40,3
40,4
40
41,3
38,1
26,9
25,7
31,6
26,4
29,4
62,8
64,4
56,9
67,1
53,2
31,4
31,7
30
34,2
23,1
44,4
44,4
44,6
44,6
43,9
61,6
62,6
57,9
61,7
61,8
24,7
22,9
31,4
22,8
29,1
54,9
53,7
60,0
55,3
53,8
15,3
15,3
15,4
14,1
18
11,4
11,7
10,5
11,9
8,8
12,6
12,8
11,8
10,1
17,7
13,7
14,6
10
10,5
23,1
0% 20% 40% 60% 80% 100%
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
low dose moderate dose high dose
low intermediate high
Metoprolol < 25 25 – 199 > 200
Bisoprolol < 2.5 2.5 – 9.9 > 10
Carvedilol < 12.5 12.5 - 49.9 > 50
Brno 2 betablockers
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Batablocker dosing
Betablocker
(N= 777)
Metoprolol
(N= 312)
Bisoprolol
(N= 252)
Carvedilol
(N= 124)
44,5
45
43,1
44
45,9
26,6
26,4
27,1
25,2
30,1
62,3
64
53,7
60,1
70,8
54
49,4
65,7
50,7
57,4
41,1
40,4
43,1
40,5
42,0
60,3
59,9
61,2
59,9
60,2
34,1
32,7
41,5
36,0
27,1
32,3
36,0
22,9
30,4
35,2
14,4
14,6
13,8
15,5
12,1
13,1
13,7
11,8
14,9
9,7
3,6
3,3
4,9
3,9
2,1
13,7
14,6
11,4
18,8
7,4
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
low dose moderate dose high dose
low intermediate high
Atorvastatin < 10 11 – 79 > 80
Simvastatin < 20 21 – 79 > 80
Fluvastatin < 20 21 – 79 > 80
Brno 2 statins
Institute of Biostatistics and Analyses Masaryk Universitywww.iba.muni.cz; www.muni.cz
Statin dosing
Statins
(N= 786)
Atorvastatin
(N= 555)
Simvastatin
(N= 123)
Fluvastatin
(N= 75)
16,3
15,9
17,9
13,4
24,1
7,2
7,3
7,1
7,4
7
70,2
70
71
59,2
86
67,9
67,4
69,8
70,9
60,1
87,7
86,7
91,3
86,9
89,4
26,4
25,6
29,0
35,2
14,0
2,7
3,4
2,2
3,4
15,7
16,7
12,3
15,8
15,8
5,1
6,1
5,7
3,5
3,3
4,4
5,6
97,3
96,6
100
97,8
96,6
0% 20% 40% 60% 80% 100%
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
Total
Men
Women
70 or younger
over 70
low dose moderate dose high dose
4 drug groups 75.8%
RAAS blockade 92.2%
Beta blockade 91.5%
Statins 92.6%
Antiaggregation 94.0%
Brno 2 Pharmacotherapy - 1
High dose ACEI 15.3%
Perindopril 11.4%
High dose statins 15.7%
Atorvastatin 5.1%
Brno 2 Pharmacotherapy - 2
Average age Men 59.0 years
Average age Women 65.5 years
Brno 2 Conclusions - 1
BP < 140/90 60.1%
ISH 19.6%
Chol < 5.0 mmol/l 72.5%
All 4 drugs 75.8%
Each drug group > 90%
Brno 2 Conclusions - 2
Insufficient dosing of ACEI, betablockers and statins
Brno 2 Conclusions - 3
Czech republic is among the best in Europe in pharmacotherapy of patients post MI and
in achievement of target values.
Brno 2 Conclusions - 4
Recommended
