The Prevention Of Cardiovascular Disease: Have We Really Made Progress?

Thomas A. Pearson

Disclosures

Health Affairs. 2007;26(1):49-60. 

In This Article

Secondary Prevention For Adult Patients With Coronary And Other Atherosclerotic Vascular Disease

American Heart Association (AHA)/ACC Guidelines: 2006 Update.

The enormous evidence base regarding intervention to prevent vascular disease recurrence and death was first distilled into secondary prevention guidelines, with the most recent in 2006.[17] These guidelines set down goals for risk behavior, physiologic risk factors, and prophylactic interventions in CVD patients (

Exhibit 2.

 

Goals Of Secondary Prevention For Adult Patients With Coronary And Other Vascular Disease: 2006 AHA/ACC Guidelines

).

Policy Issues in Secondary Prevention.

Unresolved Scientific Issues. The secondary prevention guidelines of the AHA/ACC have not met with much controversy, given the depth of evidence supporting them. One unresolved issue is the low density lipoprotein cholesterol (LDL-C) goal in CVD patients. Several clinical trials have suggested that patients whose LDL-C levels are lowered below 100 mg/dl have fewer events than those just reaching that LDL-C goal.[18] Aloweringtolessthan70 mg/dl is considered reasonable. This degree of reduction often requires multiple cholesterol-lowering drugs with implications for drug costs, side effects, and the need to engage a lipid specialist. The lowering of the LDL-C goal is likely less of an efficacy issue and more of a cost-effectiveness issue. Second, interventions on other lipid fractions (for example, high-density lipoprotein cholesterol [HDL-C], triglycerides) might provide a better opportunity than interventions to lower LDL-C levels even further. A third issue is the need for combinations of prophylactic drugs. The guidelines currently recommend aspirin, clopidogrel (for twelve months), beta-blockers, angiotensin-converting enzyme (ACE) inhibitors for poor left ventricular function, and usually a cholesterol-lowering drug such as a statin. The evidence supporting the efficacy of each of these drugs is derived from placebo-controlled, single-drug trials. As each intervention reduces risk and improves survival, the residual risk becomes less and less, with less cost-effectiveness. Recent proposals for combination of generic drugs into a single pill, so named the Polypill, are attractive because of very low drug costs with improvements in compliance and safety.[19]

Health care provider compliance. A treatment gap persists in the implementation of the guidelines. For example, use of aspirin, lipid-lowering drugs, and smoking intervention counseling varies considerably from one hospital to the next. Two initiatives have helped reduce this variability. First, secondary prevention guidelines were included in the earliest quality-of-care indicators. Thus, numerous third-party payers, governmental organizations, and other entities scrutinize and value the attainment of secondary prevention goals. Second, professional societies and voluntary health agencies have developed hospital-based programs to improve and maintain compliance with the guidelines, including the AHA s Get with the Guidelines Program and the ACC s Guidelines Applied to Practice Program.[20] Such programs should be extended to ambulatory care settings.

Patient compliance. Many studies demonstrate high rates of noncompliance with secondary prevention guidelines. For example, the HMG-CoA reductase inhibitors (statins) need six to twelve months of use to cause a measurable reduction in CVD events. Yet compliance studies have frequently documented 50 percent or less compliance with these agents after six to twelve months.[21] Cost of the multiple drugs required in secondary prevention is often cited as a barrier to compliance, yet even 81 mg of aspirin, available without prescription for pennies per day, has a 10 percent or greater noncompliance rate.

A variety of programs have been developed to improve providers and patients adherence to the guidelines. Sporadic contact (such as every six months) with a health care provider is often inadequate to maintain and reinforce complicated lifestyle modifications and pharmacologic regimens.[22] Many services for lifestyle modification or more frequent follow-up care are not reimbursed. Solutions to problems encountered in the long-term management of CVD risk have been addressed by the Chronic Care Model.[23] This model proposes the integration of at least six policy elements: a shift in emphasis in CVD management from hospital-based to ambulatory care; the redesign of the health care delivery system from an acute to a chronic care system; development of decision-support systems and specialty care programs; clinical information systems with reminders for long-term follow-up of patients; the involvement of community resources to support the patient; and the development and use of patient and family self-management support tools, including monitoring devices, risk behavior-modification aids, medication adherence reminders, over-the-counter (OTC) drugs, and support groups. The Chronic Care Model provides an example for better organizing efforts to comply with secondary prevention guidelines and a platform for effective risk-factor management. Implementation of its six elements would be reasonable considerations for resource allocation by policymakers.

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