Risk factors

Risk-guided approach to up-titration improves quality of secondary CHD prevention


Routine risk stratification of patients hospitalised with coronary heart disease can help identify where to prioritise intensive secondary prevention measures including costly PCSK9 inhibitors, Australian research shows.

A longitudinal cohort study followed up almost 20,000 patients from all public hospitals in Queensland who were hospitalised with CHD in 2010.

A third (33%) were classified as high risk for a secondary event using the validated risk score PEGASUS-TIMI54.

High-risk patients had fewer days alive and out of hospital (DAOH) within the 5-year follow-up from hospital discharge, as well as higher readmission rates and higher death rates, compared with patients in the low-risk group (all p<0.001).

Linkage with MBS and PBS data showed that patients in the high-risk group were better up-titrated for cardioprotective medications – statins, ACEi/ARB and beta-blockers – than those in the low-risk group.

“In multivariable analysis, CABG, PCI and statins were associated with greatest increases in [days alive and out of hospital],” the authors from the Baker Heart and Diabetes Research InstituteMelbourne, and Griffith University noted.

In the secondary outcome of reducing readmission, greater effect sizes were observed in the high-risk patients for most interventional and medical therapies.

“For mortality, up-titration of statins and PCI were associated with a greater reduction in death in high-risk patients than that in the low-risk group.”

“These findings suggest that high-risk patients may benefit more from up-titration of cardioprotective medications and interventions than their lower risk counterparts.”

The study, published in BMJ Open, said that CHD patients with higher risk were therefore more likely to provide a return on the investment of additional steps to reduce recurrent events.

“Our findings support risk assessment of secondary events in all CHD patients. This may have implications for the selection of patients for new and expensive medical therapies that are able to reduce CHD risks.”

The study authors said a risk-guidance strategy which prioritised high risk patients did not mean a denial of treatment in patients who are classified as low risk.

“Instead, our findings implicate that the excess risk in the high-risk group may be treatable. In circumstances where additional investment to ensure treatment-to-target or facilitate early intervention could not be provided widely to all patients, they should prioritise high-risk patients to maximise investment return.”

“A risk-guidance strategy will improve quality of care and especially benefit clinical practice in resource-constrained environments by guiding the allocation of limited resources and optimising returns on these investments.”

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