proven heart medicines improves, but not enough
Send a link to a friend
[JAN. 21, 2006]
N.C. -- While the use of medicines proven to save the lives of heart
patients has shown steady improvement, investigators at the
Duke Clinical Research Institute
have determined that there is still much need for better physician
prescribing of, and patient adherence to, lifesaving medicines,
particularly continued long-term use of these medicines.
The researchers said that,
for the most part, physicians and health care providers appear to be
doing a reasonably good job of prescribing the appropriate
medications to their heart patients at discharge from the hospital.
However, the next major challenge is to better understand the
factors that influence how consistently heart patients will continue
to take their medicines, the researchers said.
The most glaring example highlighted by the researchers is
aspirin, which was consistently used by only 71 percent of patients
in their study.
"It is eye-opening to be reminded how much work we still have to
do when, in this day and age, only 71 percent of heart patients are
taking aspirin," said Duke cardiologist Kristin Newby, M.D., lead
author of a study whose results were published online Jan. 9 in the
journal Circulation. "For a drug that is well-understood,
inexpensive, easily available and fairly well-tolerated, we should
see rates in the upper 90 percent.
"We also found that other drugs that have been proven to save
lives are even less consistently used than aspirin, such as
beta-blockers, cholesterol-lowering drugs and ACE inhibitors," Newby
said. "Our analysis showed that consistent use of these medicines
could lead to significant reductions in risk for patients with
coronary artery disease."
Specifically, the researchers found that patients who were
consistent in their use of aspirin saw a 42 percent reduction in
risk of death, while beta-blocker use led to a 37 percent reduction
and lipid-lowering medicines led to a 48 percent reduction. Patients
who took all three saw a 33 percent reduction. Among a subgroup of
the analysis, those with heart failure, consistent use of ACE
inhibitors led to a 25 percent risk reduction.
For their analysis, the team used the Duke Databank for
Cardiovascular Disease, which has collected detailed clinical
information on its cardiac catheterization patients since 1969. Each
Duke patient with coronary artery disease is contacted at least once
a year following discharge from the hospital. Since 1995, medication
use also has been collected.
In the period 1995 to 2002, the team identified 31,750 patients
with documented coronary artery disease. That group was divided into
those who did not have heart failure (71 percent) and those who did
"Among all the patients, the proportion of patients taking each
agent and combinations of agents increased over the time of the
study, with the peak for each occurring in 2002," Newby said. About
83 percent of patients reported taking aspirin, 61 percent
beta-blockers, 63 percent lipid-lowering drugs, and 39 percent
reported all three together.
"However, when we looked at those patients who were taking the
medications consistently, only 71 percent were taking aspirin,"
Newby said. "Only 46 percent were consistent in their use of beta
blockers, 43 percent for lipid-lowering drugs and 21 percent for all
[to top of second column]
For heart failure patients, use of ACE inhibitors
peaked at 51 percent in 2002, with a 39 percent consistent usage
rate, she said.
Paradoxically, the team found that those patients who would
benefit the most from the consistent use of these medication were
the least likely to be taking them.
"Those patients with heart failure, who were older or who had
other diseases had the worst overall consistent use," Newby said.
"There are still doctors who are reluctant to prescribe these drugs
to their sickest patients -- maybe not realizing that potential side
effects are far outweighed by the benefits. This represents a gap in
our understanding: Why is it that health care providers appear to
fear treating these patients as aggressively as other patients?"
Newby's analysis is part of the
Centers for Education and Research on Therapeutics demonstration
program, a national initiative to conduct research and provide
education that advances the optimal use of therapeutics, including
drugs, medical devices and biological products. The program, which
consists of seven centers and a coordinating center, is administered
as a cooperative agreement by the Agency for Healthcare Research and
Quality, in consultation with the U.S. Food and Drug Administration.
Duke is the research center for cardiovascular therapeutics and also
serves as the coordinating center for the national program.
"We as physicians have spent a great deal of time studying how
best to treat our patients while in the hospital, so now we need to
focus on better understanding the barriers to improved compliance
outside of acute medical settings," Newby said. "This will be a much
more difficult problem, since it involves so many different
The Duke team is currently organizing a randomized clinical trial
designed to better understand one facet of this complex problem. The
team plans to work with community pharmacists to see if better
communication between patients and health care providers, including
the community pharmacist, can lead to improved long-term adherence.
The American Heart Association estimates that 13.2 million
Americans have a history of coronary artery disease and therefore
are at risk of a new or recurrent cardiac event.
Other members of the Duke team were Nancy Allen LaPointe, Pharm.D.;
Anita Chen, Judith Kramer, M.D.; Bradley Hammill; Elizabeth DeLong,
Ph.D.; Lawrence Muhlbaier, Ph.D.; and Robert Califf, M.D.
[Duke University news release]