Secondary Prevention of MI in Schizophrenia Cuts CVD Mortality

Pauline Anderson

October 29, 2018

Secondary prevention in individuals with schizophrenia who have suffered a myocardial infarction (MI) cuts the mortality rate in this patient population where cardiovascular disease (CVD) outcomes are notoriously poor and tied to a vastly reduced life expectancy, new research shows.

Pirathiv Kugathasan

Investigators at Aalborg University Hospital, Denmark, uncovered a dose–response that was tied to lower mortality. MI patients with schizophrenia who received three cardioprotective treatments had the lowest death rates.

Patients suffering schizophrenia already have difficulty managing their psychiatric symptoms, so when they experience a cardiac event, they need "careful follow-up" to improve outcomes, study investigator Pirathiv Kugathasan, PhD candidate, Department of Psychiatry, Aalborg University Hospital, Denmark, told Medscape Medical News.

"If clinicians can do that, we believe that the prognosis will be much, much better," he said.

The study was published online October 24 in JAMA Psychiatry.

High Mortality Rate, Reduced Life Expectancy

Patients with schizophrenia have a relatively high mortality rate, much of it because of CVD. This contributes to a life expectancy that is 15 to 20 years shorter than the general population.

From the National Danish Patient Registry, the investigators determined the number of individuals who were hospitalized for a first MI in Denmark between 1995 and 2015. They separated patients with a diagnosis of schizophrenia from those in the general population.

The cohort included 684 patients with schizophrenia (70.6% male; mean age at MI, 57 years) and 104,334 individuals in the general population (70.4% male; mean age, 61 years).

The investigators gathered information on dispensed prescriptions for preventive treatment after an MI. They defined five drug groups: anti-platelets, vitamin K antagonists, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs), and statins. Patients were allowed to switch among therapeutic groups during the study period.

Compared with the general population, patients with schizophrenia had a lower proportion of prescriptions for antiplatelets (84.9%), vitamin K antagonists (15.9%), beta-blockers (74.1%), ACEIs (70.9%), and statins (72.2%), and a greater proportion of no prescriptions after MI (7.8%) (P < .001 for all).

The mortality rate during follow-up among patients with schizophrenia was 44.9% compared with 26.6% for other patients (P < .001). Causes of death were equally distributed between groups, and two-thirds (66.2%) of all deaths in both groups were due to CVD.

In their fully adjusted model looking at mortality rates and treatment exposure, researchers adjusted for sex, birth year, age at MI, calendar period, percutaneous coronary interventions, chronic obstructive pulmonary disease, hypertension, and substance abuse.

The analysis found that patients with schizophrenia who did not receive cardiovascular medications had a nearly nine-times greater likelihood of dying compared with treated individuals from the general population (hazard ratio [HR], 8.78; 95% CI, 4.37 - 17.64),

Excess mortality was lower among patients with schizophrenia compared with the general population if the patients received dual cardiovascular therapy (adjusted HR, 6.65; 95% CI, 3.56 - 12.40 vs HR, 1.86; 95% CI, 1.71 - 2.02, respectively).

Among study participants receiving three or more medications, patients with schizophrenia did not have an increased risk of mortality compared with patients from the general population.

"The results suggest that if patients with schizophrenia experience any kind of acute cardiac event and are well treated, intensively treated, with cardioprotective medications, this will protect them from dying early," said Kugathasan.

Research suggests that in patients with schizophrenia, other medical problems go undetected. These patients may be less likely than others to seek healthcare advice for a medical issue, such as a heart problem, perhaps because they're so focused on their mental health, said Kugathasan.

"Some studies have shown that these patients get into hospital or see a doctor at a later more severe stage. So we're not detecting it in an early phase, only when the condition is severe or they have a heart attack, for example. They may have been walking around with this condition for a long time."

There has been "much debate" recently over what preventative approaches might work in patients with schizophrenia, he said. "All the things that we have tried in the past don't help reduce mortality in patients with schizophrenia."

Kugathasan said the new findings suggest the need for better communication between psychiatrists and cardiologists.

"Critical Need" to Improve Care

Commenting on the study for Medscape Medical News, Benjamin Druss, MD, author of an accompanying editorial and professor and Rosalynn Carter chair in Mental Health, Rollins School of Public Health, Emory University in Atlanta, Georgia, said it provides "very compelling evidence that getting patients with schizophrenia appropriate treatment could have a major impact on narrowing the mortality gap."

There's a "critical" need to improve access to treatment for patients with schizophrenia, said Druss.

In the United States, that means developing better linkages between the public mental health sector and both primary care and specialty medical providers such as cardiologists, he said.

Undertreatment of patients with schizophrenia is partly because of the current system of "fragmented" care, where such patients get treated in different places for their mental health and primary care. "They can fall through the cracks," he said.

"There's also some indication that because they're poor and not insured or underinsured, they may have less access to good quality care."

Druss was surprised that even in Denmark, which has a universal healthcare system, the problem of adequate care for patients with schizophrenia still exists.

"Even taking care of the access issue, you still see this big gap," he said. "I would worry that the problem would be even larger in the United States because of the lack of universal access to insurance."

Kugathasan and Druss have reported no relevant financial relationships.

JAMA Psychiatry. Published online October 24, 2018. Abstract, Editorial

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