Inequalities in the provision of guideline-directed medical therapy following myocardial infarction

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Abstract Background Following myocardial infarction, secondary preventative medication is recommended to reduce residual cardiovascular risk. Insights into the short- and long-term trends in the provision of guideline-directed medical therapies by sex, age, ethnicity and social deprivation may help identify inequalities in contemporary post-myocardial infarction care. Purpose To evaluate short- and long-term patterns in the provision of guideline-directed medical therapies in patients following myocardial infarction by sex, age categories, ethnicity and social deprivation groups. Methods This observational cohort study using linked routine healthcare data identified all adults with a hospital admission record of myocardial infarction between April 1, 2009 and August 1, 2021, in South-east Scotland. Multivariable logistic regression models with a generalized estimating equation approach were used to assess short- and long-term provision of optimal guideline-directed medical therapy across sex (female, male), age categories (<50, 50 to 70, >70 years), ethnicity (white, other than white), and area-based social deprivation groups (group 1, most deprived; group 3, least deprived). Optimal guideline-directed therapy was defined as the dispensing of an antiplatelet agent, lipid-lowering therapy, and renin-angiotensin system blocker, and was evaluated at 3-, 12-, and 18-months post-discharge. Multivariable cause-specific Cox proportional hazard models were used to evaluate medication status and risk of a composite of non-fatal myocardial infarction, non-fatal stroke, or cardiovascular death across subgroups. Results A total of 7,926 patients with acute myocardial infarction were included (35% female, mean age 65 [standard deviation, 13] years). At 3 months, 5,380 (68%) patients were on optimal, 2,169 (27%) on suboptimal, and 215 (3%) on no medication (Figure 1). After adjustment, women and both younger- (<50 years) and older (>70 years) patients were less likely to be on guideline-directed medical therapy at all three time points (Figure 2). No differences were observed across ethnicity and social deprivation groups. Patients on either optimal or suboptimal medication had a lower risk of future cardiovascular events compared to those on no medication, with this effect being consistent across all subgroups and time points. Conclusions Women, younger and older patients are less likely to be on optimal guideline-directed medical therapy following myocardial infarction, despite its benefit in reducing future cardiovascular events. Targeted strategies to increase the provision of secondary prevention are needed to reduce inequalities and improve post-myocardial infarction care and outcomes.

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