Prescribing Pattern of Cardiovascular Drugs and Quality of Life in Myocardial Infarction Patients: An American Heart Association-based Evaluation

INTRODUCTION

Cardiovascular diseases collectively account for approximately 17.5 million fatalities annually, thereby constituting the predominant global cause of morbidity and mortality. Myocardial infarction (MI), representing the predominant clinical manifestation of coronary artery disease (CAD), ensues when a coronary artery undergoes stenosis, typically as a consequence of atherosclerotic plaque rupture, followed by thrombus formation.^[1] This critical impairment in coronary perfusion precipitates a profound attenuation in oxygen and nutrient delivery to the myocardial tissue distal to the obstruction,^[2] culminating in ischemic necrosis of the affected myocardial territory.^[3] There are atherosclerotic and nonatherosclerotic causes that can lead to MI.^[4] Atherosclerotic causes include myocardial ischemia, acute plaque rupture, and role of platelets. Non-atherosclerotic causes include vasospasm, arteritis, embolism, thrombotic diseases, trauma, aneurysm, and compression due to tumor.^[5] In addition, sedentary lifestyles, central (visceral) adiposity, a positive familial predisposition to CAD, and persistent psychological stress represent salient modifiable and non-modifiable risk factors.^[6,7] These variables frequently coexist and interact synergistically, exacerbating the overall cardiovascular risk profile.^[8] Acute MI (AMI) is frequently accompanied by life-threatening complications, including malignant arrhythmias, decompensated congestive heart failure, cardiogenic shock, and thromboembolic events.^[9,10] A principal diagnostic modality for AMI involves the quantitative assessment of specific cardiac biomarkers such as creatinine kinase, lactate dehydrogenase, and cardiac troponins. Studies show that there is still a significant underuse of revascularization procedures such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in AMI^[11,12] as well as a deficit in the prescribing pattern of core cardiovascular therapy. Statins, antiplatelet drugs, anticoagulants, angiotensin-converting enzyme inhibitors, or beta-blockers are considered core cardiovascular therapy.^[13] Core cardiovascular therapy is used to prevent further infarction or death due to MI following revascularization procedures; hence, they are considered to be secondary prophylaxis.^[14] Our study evaluates the prescribing pattern of core cardiovascular drugs in post-MI patients and assesses their adherence to American Heart Association (AHA) guidelines. Prescriptions consistent with guidelines are considered good adherence, while deviations from guidelines are classified as poor adherence. Based on this, we examine the impact of adherence on patient’s health-related quality of life (HRQoL).^[15,16] A systematic review examining HRQOL in individuals with stable CAD during the 1–3-year period following MI identified significant methodological deficiencies across the evaluated studies.^[17] Furthermore, the temporal scope of patient follow-up was markedly constrained, with the majority of studies limiting their observational windows to short-term durations.^[18] This methodological insufficiency compromises the capacity to capture the long-term trajectory of HRQoL and its determinants in post-MI populations, thereby impeding the development of sustained, patient-centered care strategies.^[19] The EQ-5D-3L is an HRQoL instrument with five dimensions of health (mobility, self-care, usual activities, pain and discomfort, anxiety and depression), for which there are three levels of answer (no problems, some problems, and severe problems).^[20,21]

MATERIAL AND METHODS

It is a prospective observational study which was conducted in the Department of Cardiology at Karpagam Faculty of Science and Research in Coimbatore, Tamil Nadu. This study aimed to analyze the current prescribing trends in the management of MI patients and compare it with standard AHA guidelines and its impact on the quality of life in MI patients. This study spanned a period of 6 months with a total sample size of 140 participants. The sample size calculation was based on Cochran’s formula (n = Z²×P (1−P)/d²).

Were,

n = required sample size

Z = normal deviation (1.96)

P = proportion of adherence

d = margin of error (0.05)

Sample size calculation

Z = 95% Confidence interval which is equal to 1.96

P = 0.1% (estimated prevalence of poor adherence from prior studies)

d = 0.05

n = 138 which is rounded to 140.

RESULTS

Total sample size: 140.

DISCUSSION

This study, conducted at Karpagam Medical Science and Research, evaluated 140 MI patients to analyze both their quality of life and the prescribing pattern in which the latter’s adherence was compared with AHA guidelines. The study revealed a clear predominance of male patients (68.13%) which may be due to the higher prevalence of vascular risk factors among men. Lifestyle factors such as smoking, alcohol consumption, and sedentary behavior are known contributors to cardiovascular disease, particularly in men. In contrast, premenopausal women benefit from the cardioprotective effects of endogenous estrogen, which delays the onset of MI. Once menopause occurs and estrogen levels decline, this protective effect diminishes, aligning with similar observations from the Anantapur study by Palli et al. (2023).^[22]

Age-wise distribution revealed that a significant proportion of the patients fell within the 50–60 years (28.3%) and 60– 70 years (24.6%) age groups. These age ranges represent a critical stage in cardiovascular disease development, often due to prolonged exposure to interrelated risk factors such as hypertension, poor glycemic control, and dyslipidemia. With aging, vascular remodeling and endothelial dysfunction become more prevalent, both of which increase susceptibility to adverse cardiac events. These observations align with Kim.^[23]

Regarding comorbidities, hypertension (36.45%) and DM (24.34%) were the most commonly observed. Notably, 55 patients (39.3%) did not present with any comorbid condition. Hypertension and diabetes are well-documented modifiable risk factors for MI. Chronic high blood pressure leads to arterial damage over time, while hyperglycemia contributes to endothelial dysfunction and atherogenesis.

The adherence of prescribed drugs to the AHA guideline recommendations was evaluated by comparing the percentage of prescriptions for each drug with the guideline’s recommended therapy for MI. Drugs that were recommended by AHA and prescribed to more than or equal to 75% of eligible patients were categorized as showing good adherence. Drugs prescribed to 50–74% of eligible patients were considered as showing moderate adherence, and those prescribed to <50% were classified as poor adherence. Descriptive statistical analysis was performed using frequency and percentage distribution. Since the study was observational and descriptive, inferential statistics were not applied; instead, adherence was interpreted based on proportional compliance with guideline-recommended therapy. On analyzing the prescribing patterns, dual antiplatelet therapy, aspirin (100%) and ticagrelor (83.1%), was used in patients, which showed good adherence toward the guidelines. The use of clopidogrel (27.9%) is limited because of its specific use in elderly patients and those receiving fibrinolytics. Although statins were prescribed in 75.5% of patients, it showed underutilization in comparison with guidelines as nearly 29.1% of patients did not receive any statins, which represents a major gap in pharmaceutical care. With anticoagulant therapy, unfractionated heparin (84.1%) was used predominantly and showed good adherence toward guidelines but 15.2% of the patients did not receive any. On compliance with guidelines, antihypertensive agents such as metoprolol (40%) were commonly prescribed. However, administration of calcium channel blockers, diuretics, and their associated variable dosing shows inconsistent application of personalised medicine.

To assess quality of life, the EQ-5D-3L questionnaire was utilized, focusing on five key domains: Mobility, self-care, usual activities, pain/discomfort, and anxiety/depression, consistent with the methodology used by Dyer et al. (2010).^[24] The findings linked these domains to the prescribed drug classes, especially those used in MI management. Most patients reported significant issues in mobility, pain/discomfort, and self-care, highlighting these as critical areas impacting post-MI recovery. Moderate issues were noted in the anxiety/depression domain, underscoring the mental health burden of MI. Severe challenges in self-care and depression were reported by only a small number of patients, indicating fewer but serious cases requiring further clinical attention.

Notably, our study demonstrated a statistically significant association between core cardiovascular pharmacotherapy (antiplatelet, anticoagulant, antihypertensive, and statins) and its prominence in improving the quality of life. Here, the latter was assessed with EQ-5D-3L questionnaire.

Antiplatelets were strongly correlated with better self-care (P = 0.049) and usual activity (P = 0.039), anticoagulants with self-care (P = 0.017) and pain/discomfort (P = 0.045), antihypertensive with mobility (P = 0.017), self-care (P = 0.006), and pain/discomfort (P = 0.014), Statins with reduced anxiety/depression (P = 0.016). The overall statistical correlation revealed a significant association with antiplatelets (P = 0.000), statins (P = 0.018), and anticoagulants (P = 0.035) whereas antihypertensives (P = 0.734) show relative insignificance.

A strong correlation was observed between the use of antiplatelets, statins, and anticoagulants and improvements in quality of life, aligning with the study by Ferrières et al. (2009).^[25] A systematic review further emphasized the relevance of HRQOL assessments, including those employing EQ-5D-3L tools, to track long-term patient outcomes and assess the broader impact of therapeutic interventions such as antiplatelet and anticoagulant therapies.^[26-30]

CONCLUSION

The study revealed that usage of most of the core cardiovascular therapies aligns with the standard AHA guidelines. However, certain medicines show deviations from the standards. Statistical analysis highlighted that core cardiovascular therapies had a considerable association with specific quality of life domains. However, several domains showed P > 0.05, revealing no significant relationship. Improving adherence toward guidelines in addition to individualized pharmacotherapy may refine both clinical outcomes and quality of life in MI patients. Further research should concentrate on long-term follow-up studies.