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Importance of long-term maintenance of preventive therapies after CV event ‘underappreciated’

By Nicole MacKee
Almost one in four patients with chronic ischaemic cardiovascular disease has died or been rehospitalised within six months of follow up, researchers have reported in the European Journal of Preventive Cardiology.

Researchers evaluated 2203 patients with stable coronary artery disease or peripheral artery disease (PAD) who were enrolled in the Chronic Ischaemic Cardiovascular Disease Pilot Registry across 10 European countries. The researchers found that during follow up 522 patients (23.7%) experienced all-cause rehospitalisation or death, with 58 patients (2.6%) dying. About three-quarters of the events were cardiovascular, the researchers reported.

Patients who experienced an event were more likely to be older or have a history of non-ST-segment elevation myocardial infarction, chronic kidney disease, peripheral revascularisation or chronic obstructive pulmonary disease than those who did not. Patients with PAD had the worst prognosis of all patient groups, the researchers reported.

The study found a mild but significant decline in the prescribing rates of ACE inhibitors, beta blockers and aspirin in the study period. Prescribing rates of statins were unchanged.

Professor John Amerena, Director of the Geelong Cardiology Research Unit, said there was an underappreciation of the importance of long-term maintenance of preventive therapies after a cardiovascular event.

‘The temptation is to drop off medication as time goes on, and the more remote it gets from the event the more likely this is to occur,’ he told Cardiology Today. ‘There is always going to be some drop off, however, as some people don’t go to their doctor, cannot afford medication or have side effects – but we should do everything we can to encourage adherence to guideline-recommended medication over time, and not just for the first few months after they have had an event.’

Professor Amerena said the research found that PAD was one of the most potent risk factors for coronary events. The detection of PAD was challenging, he said, particularly in inactive patients, who could have occult disease but no symptoms.

‘PAD is certainly underappreciated as one of the most potent risk factors for coronary events and unstable angina,’ he said. ‘It’s often asymptomatic until it’s really severe and the patient gets claudication. Then suddenly the penny drops that patients could have blockages in the arteries in their legs and investigation with a view to intervention is undertaken.’

Professor Amerena said a structured follow-up program at one, six and 12 months focusing on risk management and adherence to guideline-recommended therapies, in addition to monitoring blood pressure and cholesterol levels, would be beneficial in patients who had had an acute coronary syndrome (ACS). He acknowledged, however, that this could be difficult within the time constraints of general practice.

‘Hopefully longer adherence to proven guideline-based therapies after ACS will reduce recurrent events in these patients. But when they are older, and have other comorbidities, sometimes patients are not followed as closely as ideal and don’t take optimal therapy from a cardiovascular perspective.’
Eur J Prevent Cardiol 2018; 25: 377-387.