Guideline-directed medical therapy use, persistence, and cardiovascular outcomes following ST-segment elevation myocardial infarction: a pooled analysis of three randomised trials with external registry validation

Background Implementation and long-term persistence of guideline-directed medical therapy (GDMT) following ST-segment elevation myocardial infarction (STEMI) remain suboptimal. We assessed the implementation and persistence of four-class GDMT after STEMI and its association with outcomes. Methods We performed a patient-level pooled analysis of three randomised trials of patients undergoing percutaneous coronary intervention for STEMI. GDMT was defined by the number of drug classes prescribed (0–4). External validation was conducted using a real-world PCI registry. Findings The study included 2270 patients from the randomised trials and 5643 from a real-world PCI registry. More than two-thirds of patients received all four GDMT classes at discharge (ranging from 66.9% [398/595] to 83.5% [339/406]), but this proportion declined over 5 years (ranging from 40.5% [408/1008] to 53.1% [276/520]). In exploratory analyses, higher GDMT class at discharge was associated with a lower risk of the composite of cardiovascular death, stroke, or myocardial infarction at 5 years (adjusted HR [95% CI] for class 4 versus 0–2: 0.49 [0.33–0.72]; class 3 versus 0–2: 0.49 [0.28–0.85]). In a time-dependent analysis, higher GDMT class during follow-up was associated with a lower risk of the composite outcome (adjusted IRR [95% CI] for class 4 versus 0–2: 0.71 [0.52–0.95]; class 3 versus 0–2: 0.59 [0.41–0.86]). Similar longitudinal patterns were observed in the real-world PCI registry. Interpretation Although the majority of patients received all four GDMT classes at discharge after STEMI, this proportion declined during long-term follow-up. In exploratory analyses, higher GDMT class was associated with a lower risk of cardiovascular events. Funding No specific funding was received for the present study. Funding for the individual trials and registry is reported in the Acknowledgements.