Overcoming Clinical Inertia in the Management of Patients with Myocardial Infarction

A retrospective analysis presented at the 75th Annual Scientific Session of the American College of Cardiology, in New Orleans, suggested that patients who have experienced a myocardial infarction could benefit from closer monitoring and more intensive lipid-lowering strategies. 

“Post-myocardial infarction patients on statin therapy remain at an elevated risk for recurrent events,” presenting author Pushan Aggarwal, MD, a second-year resident at the Allegheny Health Network in Pittsburgh, Pennsylvania, said during a moderated poster session. “Current guidelines indicate that we need to intensify their lipid-lowering strategies by potentially introducing a second agent, so that we can get their low-density lipoprotein cholesterol (LDL-C) levels down toward the goal of 55 mg/dL.” 

Aggarwal and colleagues designed a retrospective study at their tertiary center to identify lipid-management patterns post-myocardial infarction and to find out if second-line agents were routinely used and if this strategy resulted in better control of cholesterol levels. The analysis included 178 patients hospitalized with myocardial infarction who were already on statin therapy at presentation. 

“We found that LDL-C levels decreased significantly over time,” Aggarwal said. “However, despite this improvement, 61% of patients still had LDL-C levels at or above 55 mg/dL at one year, and a substantial proportion of these patients lacked lipid panel testing after this myocardial infarction. There were also racial disparities in terms of prescribing and [management strategies]. We found that African-American patients had significantly higher LDL-C levels compared to white patients.” 

The results showed that 62% of the included patients continued to use the same class of statins after myocardial infarction, and nearly three-quarters of those had no dose adjustments. Only 13 patients (7%) received a second-line agent after a heart attack. 

“Despite being a high-risk, post-myocardial infarction population, in which we would expect intensification [of therapy], lipid-lowering strategies were primarily limited to statin intensification, with minimal use of second agents,” Agarwal added, noting that clinicians may miss the opportunity to use novel non-statin therapies that can help patients reach LDL-C goals. 

Providers can use various strategies to overcome clinical inertia and improve care for underserved populations. “The first thing we can do is to make sure that, when the patient comes to the first point of contact, we repeat testing,” Aggarwal suggested. “In our system, we [have incorporated] a best practice advisory for patients presenting with acute myocardial infarction, and the doctor who completes the discharge order can order follow-up testing immediately. The best practice advisory also recommends addition of a second-line agent in patients [who need it], because a lot of these medications can be initiated without prior authorization. Then, they can be followed up in the primary care setting. We know that statin myopathy is a concern, so, instead of escalating therapy, addition of a second-line agent can get rid of those side effects.”