Cardiovascular medication after coronary computed tomography angiography: Impact of the 2019 ESC guidelines
M Johansson, M Mohammad, C Reitan, T Jernberg, E OstenfeldAbstract
Background
In 2019, the European Society of Cardiology changed the guidelines regarding initiation of optimal medical therapy in the presence of cardiovascular disease e.g. after coronary computed tomography angiography (CCTA)[1] and findings of plaques with or without obstructive stenosis.
Purpose
This study aims to investigate if medical treatment changed post guidelines regarding medical compliance and the mid-term effects on outcome.
Method
This project collated data from the national quality registry SWEDEHEART[2], and from the Drug, Death and Specialized Care Registry, including nationwide data from CCTA in Sweden, retrieved cardiovascular prescriptions, visits to specialized care and data/causes of death. Patients with CCTA in 2017–2018 (PRE-guidelines) and 2020–2021 (POST) with clinically indicated contrast-enhanced CCTA and/or non-contrast calcium score (CACS) were included. Analysis was stratified by stenosis severity (0: No stenosis; 1: <50%; 2: ≥50%), and Calcium score (CACS 0; 1–99; 100+). Drug change was defined as the difference in unique subclasses before CCTA to directly after CCTA or directly after to mid-term (after 2–3 years). Primary endpoint (MACE) was infarction, unstable angina, cardiovascular death post-CCTA or revascularization more than 6 months after CCTA. Follow-up time was 2 years 11 months.
Results
17,308 patients were included, of which 5068 PRE and 12240 POST guidelines. 17,269 had CCTA and 6,409 CACS. Patients in the POST group had more cardiovascular drugs directly after CCTA than PRE, except in patients with stenosis <50% where it was similar (Table 1). The POST group had more lipid lowering drugs than PRE directly after CCTA and at mid term. Drug changes before and directly after CCTA, and after CCTA to mid-term were overall similar between groups. While lipid lowering drugs were similar at mid-term, antihypertensives and anticoagulants decreased (Figure 1). The greater the stenosis severity the higher proportion of drugs were removed in both PRE and POST groups at mid-term. MACE occurred in 1,945 patients, of which 615 (12.1%) in the PRE group and 1330 (10.9%) in POST (p=0.01). In POST time to MACE increased by 1.8% (p=0.02) for stenosis severity 1. For CACS, no difference in MACE between PRE and POST was significant.
Conclusion
After the 2019 ESC guidelines on chronic coronary syndrome, cardiovascular drug compliance increased on a national level in patients investigated with CCTA in Sweden. However, lipid lowering drugs were largely unchanged at mid-term. The decrease in antihypertensives and anticoagulants at mid-term indicates lower drug compliance 2-3 years after CCTA. Disadvantageously, the drug compliance decreased the most in patients with obstructive stenosis (>50%). Still, the POST guidelines group appears to have fewer events, especially in patients with any type of stenosis. This emphasizes the importance of prescription compliance of optimal medical therapy.