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Secondary Prevention Therapies in Patients with Non-Obstructive Coronary Artery Disease: Insights from the NCDR ® CathPCI Registry ®. Thomas M. Maddox MD, MSc ; P. Michael Ho, MD, PhD; Matthew Roe MD, MHS; David Dai, MSc ; Thomas T. Tsai MD, MSc ; John S. Rumsfeld MD, MD, PhD

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  1. Secondary Prevention Therapies in Patients with Non-Obstructive Coronary Artery Disease: Insights from the NCDR®CathPCI Registry ® Thomas M. Maddox MD, MSc; P. Michael Ho, MD, PhD; Matthew Roe MD, MHS; David Dai, MSc; Thomas T. Tsai MD, MSc; John S. Rumsfeld MD, MD, PhD Denver VAMC/University of Colorado Denver, Denver CO (Drs. Maddox, Ho, Tsai, and Rumsfeld); Duke Clinical Research Institute, Durham, NC (Dr. Roe, Mr. Dai)

  2. Funding Support and Disclaimer This research was supported by the NCDR (National Cardiovascular Data Registry). The views expressed in this presentation represent those of the author(s), and do not necessarily represent the official views of the American College of Cardiology Foundation or NCDR registry partners.

  3. During catheterization, CAD plaques are often categorized into obstructive or non-obstructive stenosis for revascularization decisions

  4. However, prior studies show no correlation between plaque stenosis and subsequent MI Little WC, et al. Circulation; 78: 1157-1166, 1988

  5. MI rates in CAD patients are reduced with secondary prevention medications

  6. However, CAD patients with non-obstructive stenoses may receive sub-optimal secondary prevention

  7. Study Aims Primary aim: Determine prescription rates of secondary prevention medications among non-obstructive and obstructive CAD patients Secondary aim:Determine prescription rates among non-obstructive CAD patients with clear indications for secondary prevention - ACS, prior MI, or a CAD risk equivalent (CVD, PAD, DM)

  8. ~2.5 million cath reports collected between 2004-2007 Final study cohort: 1,489,745 CAD patients from 786 hospitals Study population Excluded: Patients who died/transferred to hospice Patients with missing cath or medication data Patients with no or minimal CAD (luminal irregularities, stenoses < 20%

  9. 20% 70% Classification of CAD Non-obstructive CAD All left main stenoses < 50% AND All other stenoses < 70% (N = 237,167, 15.9%) Obstructive CAD Any left main stenosis > 50% OR Any other stenosis > 70% (N = 1,252,578, 84.1%) Excluded from analysis

  10. Statistical Analysis • Primary analysis: Medication rates between non-obstructive and obstructive CAD • Secondary sub-group analysis: Medication rates between those non-obstructive CAD patients with clear indications for secondary prevention and obstructive CAD patients • Multivariable logistic regression using generalized estimating equations • Adjusted for patient, procedure, and hospital characteristics • First-order interaction term to gauge impact of increasing degree of CAD obstruction

  11. Baseline characteristics All p-values <0.001

  12. - Obstructive CAD - Non-Obstructive CAD Rates of Medication Prescription by Degree of CAD Obstruction 100% 90.9% 80.2% 79.3% 72.5% 59.8% 58.6% 57.8% 45.9% 50% 0% Aspirin Statins Beta-blockers ACEI/ARBs

  13. 0.37 (0.35, 0.39) 0.45 (0.43, 0.48) 0.46 (0.44, 0.47) 0.83 (0.8, 0.87) Adjusted odds ratios of prescription in non-obstructive CAD patients, compared to obstructive CAD Aspirin Statins Beta-blockers ACEI/ARBs 1 More likely to receive medication Less likely to receive medication

  14. Sub-group of non-obstructive CAD patients with clear guideline indications for secondary prevention Primary study cohort: 237, 167 patients with non-obstructive CAD Sub-group cohort with ACS, prior MI, or CAD risk equivalent (CVD, PAD, or DM): 170,482 (71.9%)

  15. 0.32 (0.3, 0.34) 0.42 (0.4, 0.45) 0.41 (0.39, 0.42) ACS sub-group of non-obstructive CAD patients, compared to obstructive CAD Aspirin Statins Beta-blockers 0.81 (0.78, 0.85) ACEI/ARBs 1 Less likely to receive medication More likely to receive medication

  16. 0.42 (0.39, 0.44) 0.54 (0.5, 0.57) 0.52 (0.5, 0.54) Prior MI or CAD risk equivalent sub-group of non-obstructive CAD patients, compared to obstructive CAD Aspirin Statins Beta-blockers 0.85 (0.82, 0.89) ACEI/ARBs 1 Less likely to receive medication More likely to receive medication

  17. Limitations • No core angiography laboratory • Misclassification likely non-differential • Incomplete characterization of medication contraindication • Misclassification likely non-differential • No post-discharge secondary prevention data • Lower rates of discharge medication is associated with lower rates of medication in the out-patient setting

  18. Conclusions • Presence of non-obstructive CAD is significantly and strongly associated with lower rates of secondary prevention prescription at hospital discharge • Lower prescription rates persist among non-obstructive CAD patients with clear indications for secondary prevention

  19. Implications • Improvements in rates of secondary prevention medication prescription among non-obstructive CAD patients with ACS, prior MI, or CAD equivalents are needed • Outcome studies of secondary prevention among patients with non-obstructive CAD without current indications are needed • Non-obstructive CAD may represent an “emerging risk factor”

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