Age and sex inequalities in the prescription of evidence-based pharmacological therapy following an acute coronary syndrome in Portugal: the EURHOBOP study

Abstract

Aim: To assess the proportion of patients receiving pharmacological therapy for secondary prevention after an acute coronary syndrome (ACS) in Portugal and to identify age and sex inequalities.

Design: Retrospective cohort study.

Methods: We studied 747 episodes of ST-segment elevation myocardial infarction (STEMI) and 1364 of non-ST-segment elevation ACS (NSTE-ACS), within a sample of ACS cases consecutively discharged from 10 Portuguese hospitals, in 2008-2009. We estimated adjusted odds ratios (OR) for the association of age and sex with the use of each pharmacological treatment.

Results: In STEMI and NSTE-ACS patients, the proportion of patients discharged with aspirin was 96 and 88%, clopidogrel 91 and 78%, aspirin+clopidogrel 88 and 71%, beta-blockers 80 and 76%, angiotensin-converting enzyme (ACE) inhibitors/ARB 82 and 80%, statins 93 and 90%, 3-drug (aspirin/clopidogrel+beta-blocker+statin) 76 and 69%, and 5-drug treatment (aspirin+clopidogrel+beta-blocker+ACE inhibitor/ARB+statin) 61 and 48%, respectively. Among STEMI patients, those aged ≥80 years were substantially less often discharged with clopidogrel (OR 0.22, 95% confidence interval, CI, 0.08-0.56), aspirin+clopidogrel (OR 0.34, 95% CI 0.15-0.76), beta-blockers (OR 0.39, 95% CI 0.18-0.82), 3-drug (OR 0.41, 95% CI 0.21-0.83), and 5-drug treatments (OR 0.44, 95% CI 0.23-0.83) than those <60 years; women were less likely to be discharged with aspirin+clopidogrel (OR 0.52, 95% CI 0.29-0.91). Among NSTE-ACS patients, those aged ≥80 years were much less likely to be discharged with beta-blockers (OR 0.58, 95% CI 0.36-0.93), statins (OR 0.35, 95% CI 0.19-0.64), and 3-drug treatment (OR 0.47, 95% CI 0.30-0.75); sex had no significant effect on treatment prescription.

Conclusions: The vast majority of younger patients were discharged on evidence-based secondary preventive medications, but only half received the 5-drug combination. Recommended therapies were substantially underprescribed in older patients.

Keywords: Acute coronary syndrome; age; inequalities; secondary prevention; sex.