1. Pharmacotherapy after myocardial infarction The reality of coronary prevention in Brno, or else Is pharmacotherapy after myocardial infaction sufficient. The reality of coronary prevention in Brno, or else Is pharmacotherapy after myocardial infaction sufficient.

2. REPERFUSION

3. PTCA

4. Direct PCI for all STEMI

5. PTCA 60/1,000,000 = 1992 624/1,000,000 = 1998 1,220/1,000,000 = 2006 20x

6. PTCA 60/1,000,000 = 1992 624/1,000,000 = 1998 1,220/1,000,000 = 2006 2,250/1,000,000 = 2009 37x

7. STENT 5/1 000 000 = 1992 449/1 000 000 = 1998 1 082/1 000 000 = 2007 200x

8. STENT 5/1 000 000 = 1992 449/1 000 000 = 1998 1 082/1 000 000 = 2007 2 850/1 000 000 = 2009 570x

9. REMODELATION REPERFUSION RETHROMBOSIS RESTENOSIS 4R

11. Beta blockade RAAS blockade Statins Antiaggregation

12. Registry Brno 2

13. Methods Collection of data on patients with history of myocardial infarction > 1 month. Outpatient follow-up in University Hospital Brno from 1 Sept. 2009 to 31 Dec. 2009. Brno 2 registry of patient post myocardial infarction

14. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz 850 pts - age and gender Number% Total850 GenderM (male)65076.5% F (female)20023.5% Age 70 years or younger 57668.6% over 70 years 26431.4% Age – mean (SD);median (5- 95%) 64 (10.8); 64 (46-82) Age (years) % of patients Age ( category ) 70 years or younger over 70 years Gender MaleFemale N = 850

15. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Number of myocardial infarctions and age at the first infarction TotalMaleFemale 70 years or younger over 70 years Number of MIs: 1 x MI87.8%87.5%88.5%90.3%83.0% 2 x MI9.5% 8.0%12.1% more than 2 x MI2.7%2.9%2.0%1.7%4.9% Age at time of first MI (years) % of patients N = 850 1 st MI Total 60.5 years Men 59.0 years Women 65.5 years

16. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Blood pressure less than 130/80130/80 to 140/90more than 140/90 Total (N=850) Men (N=650) Women (N=200) 70 years or younger (N=576) over 70 years (N=264)

17. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Blood pressure categories Optimal BPNormal BPHigh normal BP HT 1st degree HT 2nd degree HT isol. diastolic HT isol. systolic HT 3rd degree. * significant difference at level 0.05

18. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Blood pressure N = 850 mmHg 75% Median 25% 95% 5% BP - systole mmHg BP - diastole over 70 years 70 years or younger FemaleMaleTotal 70 years or younger 70 years or younger Over 70 years TotalMenWomenTotalMenWomen

19. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Heart rate N = 850 75% Median 25% 95% 5% Pulse (per minute) over 70 years 70 years or younger FemaleMaleTotal # significant difference at level <0.001 # 70 years or younger Over 70 yearsTotalMenWomen*

20. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Cholesterol less than 4.5 mmol/l4.5 to 5 mmol/l more than 5 mmol/l ** * significant difference at level 0.05 ** significant difference at level 0.01 Total (N=850) Men (N=650) Women (N=200) 70 years or younger (N=576) over 70 years (N=264)

21. BP < 140/90 mmHg – 60.1% ISH – 19.6% Cholesterol < 5 mmol/l - 72.5% Brno 2 Achievement of target values

22. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Medication ACEI or ARB only ACEI only ARB ACEI and ARB Betablocker Statins ASA or Clop. only ASA only Clop. ASA and Clop. Total (N=850)Men (N=650)Women (N=200) 70 yrs or younger (N=576) over 70 years (N=264) RAASBetablockersStatinsAntiaggregation

23. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Medication – drug combinations All groupsTriple combinationDouble combination1 group of drugs Antiaggregation - 0.5% RAAS - 0.2% Statins - 0.2% BB-Antiaggregation - 1.1% BB-Statins - 0.2% RAAS-Antiaggregation - 0.9% RAAS-BB - 0.2% RAAS-Statins - 0.7% Statins-Antiaggregation - 0.4% BB-Statins-Antiaggregation - 5.4% RAAS-BB-Antiaggregation - 4.5% RAAS-BB-Statins - 4.2% RAAS-Statins-Antiaggregation - 5.5% N = 850

24. low intermediate high Perindopril 10 Ramipril 10 Trandolapril 4 Brno 2 ACE inhibitors

25. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz ACEI dosing ACEI ( N= 631) Perindropril (N= 271) Ramipril (N= 240) Trandolapril (N= 51) low dosemoderate dosehigh dose

26. low intermediate high Metoprolol 200 Bisoprolol 10 Carvedilol 50 Brno 2 betablockers

27. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Batablocker dosing Betablocker (N= 777) Metoprolol (N= 312) Bisoprolol (N= 252) Carvedilol (N= 124) low dosemoderate dosehigh dose

28. low intermediate high Atorvastatin 80 Simvastatin 80 Fluvastatin 80 Brno 2 statins

29. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Statin dosing Statins (N= 786) Atorvastatin (N= 555) Simvastatin (N= 123) Fluvastatin (N= 75) low dosemoderate dosehigh dose

30. 4 drug groups 75.8% RAAS blockade 92.2% Beta blockade91.5% Statins 92.6% Antiaggregation 94.0% Brno 2 Pharmacotherapy - 1

31. High dose ACEI 15.3% Perindopril 11.4% High dose statins 15.7% Atorvastatin 5.1% Brno 2 Pharmacotherapy - 2

32. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Medication in relationship to blood pressure HT 1st degree ( N= 74) HT 2nd degree (N= 34) HT 3rd degree (N=8)* Blood pressure low dosemoderate dose high dose RAAS dosingBB dosingBoth doses high * Due to low number of patients in these categories, results are only for rough information

33. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz BB dosign based on heart rate HR ≥ 100 N=6 HR 99-90 N=19 HR 89-80 N=70 low dosemoderate dosehigh dose

34. Institute of Biostatistics and Analyses Masaryk University www.iba.muni.czwww.iba.muni.cz; www.muni.czwww.muni.cz Medication in relationship to cholesterol levels ≥ 6.0 mmol/l ( N= 68) 5.0–5.9 mmol (N= 155) 4.5–4.9 mmol (N= 142) <4.5 mmol/l (N= 446) Cholesterol low dosemoderate dosehigh dose Statin dose no statins

35. Average age Men59.0 years Average age Women65.5 years Brno 2 Conclusions - 1

36. BP < 140/90 60.1% ISH 19.6% Chol < 5.0 mmol/l 72.5% All 4 drugs 75.8% Each drug group > 90% Brno 2 Conclusions - 2

37. Insufficient dosing of ACEI, betablockers and statins Brno 2 Conclusions - 3

38. Czech republic is among the best in Europe in pharmacotherapy of patients post MI and in achievement of target values. Brno 2 Conclusions - 4