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Careful use of medications can control risk factors
Advances in pharmacologic therapy allow physicians to prolong the lives of patients with heart disease and prevent or slow the development of the disease among those at risk. But in a comprehensive review of medical literature, Gideon Bosker, MD, assistant clinical professor at Yale University School of Medicine in New Haven, CT, found that physicians often aren’t taking advantage of the available tools.
He suggests these key steps toward improving "cardioprotection":
By their nature, performance assessment indicators focus on specific treatments and end points, such as beta-blocker use after myocardial infarction. But prevention of a primary or recurrent heart attack requires a careful screening of patients and prescription to address all significant risk factors, Bosker says.
"Each individual has a different constellation of risk factors. We need to customize the cocktail for cardioprevention’ to fit the needs of the individual patient," he says. "If an elderly patient has a lipid disorder and isolated systolic hypertension, the cocktail should be customized to rectify those risk factors." For example, that patient may receive a statin such as Atorvastatin and a calcium blocker such as Amlodipine, as well as counseling about lifestyle issues such as diet and exercise, Bosker says. (See table on cardioprotective cocktails, inserted in this issue.)
"We can identify those groups of patients that studies show tend to be pharmacologic outcasts when it comes to medication-based prevention of heart disease," says Bosker. Medical groups should target quality improvement and screening toward this group, he says. "They include women, the elderly, patients with heart failure, patients with hypertension without underlying heart disease, patients with hyperlipidemia, and diabetics," Bosker says.
He notes that African-Americans are often undertreated for hypertension.
Traditionally, treatment success is measured by its effect on mortality and future heart attacks. But the use of appropriate medication may also reduce the need for costly and invasive diagnostic procedures, angioplasty, and coronary artery bypass graft. "If we measure our outcomes according to this broader constellation of end points, risk-factor intervention produces results that are pharmaco-economically much more attractive than if we limit our evaluation to the traditional end points," Bosker says.
Medication use goes hand-in-hand with modification of lifestyle. Patients can make a significant impact on their cardiovascular risk by quitting smoking, reducing their dietary fat, and exercising regularly. Bosker concedes, "It is difficult to get patients to comply with lifestyle modifications, which is why so much of cardioprotection inevitably defaults to drug-based treatment."
In addition, physicians may be reluctant to add drugs to an already complex regimen. "It’s gotten to the point where patients may be taking four or five or even eight different medications," Bosker says.
The answer is to hone in on drugs that, within the framework of a single prescription agent, are sufficiently potent and effective enough to shoulder the burden for any individual risk factor, he says.
"To leave risk factors neglected is essentially to commit your patient to the placebo group. Sins of omission are essentially as potentially as harmful as sins of commission. The failure-to-prevent’ syndrome is tantamount to a permission to die prematurely unnecessarily," Bosker explains. (See box, at left.)
Side effects also may lead patients to lapse in taking their medication. After all, the disease itself may be silent and asymptomatic for many patients. "Patients need to buy into the notion that they’re taking drugs that may be costly, may have side effects, that may not make them feel any better, in exchange for the theoretical benefit of adding years of quality to their life," says Bosker.
Along with effectiveness, physicians must consider how "user-friendly" the drugs will be for patients, he says.