Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes

Background - Several individual pharmacological agents, such as antiplatelet drugs, beta-blockers, ACE inhibitors, and lipid-lowering agents, have proven efficacy in reducing mortality in patients with acute coronary syndromes. However, the impact of the combination of these agents on clinical outcomes has not been studied before. Methods and Results - A total of 1358 consecutive patients presenting with acute coronary syndromes between January 1999 and March 2002 were identified, and data on baseline demographics, comorbidities, and in-hospital management were collected. On the basis of discharge use of evidence-based therapies, we created a composite appropriateness score depending on the number of the drugs used divided by the number of the drugs potentially indicated for each patient. The impact of the composite score on 6-month mortality was analyzed using a risk-adjusted logistic regression model. The odds ratio for death for all indicated medications used ( appropriateness level IV) versus none of the indicated medications used ( appropriateness level 0) was 0.10 (95% CI, 0.03 to 0.42; P < 0.0001); similarly, odds ratio for appropriateness level III versus level 0 was 0.17 ( 95% CI, 0.04 to 0.75; P = 0.0018), odds ratio for appropriateness level II versus level 0 was 0.18 ( 95% CI, 0.04 to 0.77; P = 0.01), and odds ratio for appropriateness level I versus level 0 was 0.36 ( 95% CI, 0.08 to 1.75; P = 0.20). Conclusions - Use of combination evidence-based medical therapies was independently and strongly associated with lower 6-month mortality in patients with acute coronary syndromes. Such therapies, most of which are generic and inexpensive today, seem to offer a marked survival advantage compared with patients in whom such therapies are omitted.