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QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

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Prescription Drugs and Drug Trials Drug development - basic science research in a laboratory - chemical patented (20 years) - laboratory testing - Phase 1 trials tested for safety and efficacy in animals - Phase 2 trials tested for safety in normal humans - Phase 3 trials show effective (better than placebo or current standard treatment) and safe in many thousands of patients around the world (double blind

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Drug launched (5 years patent remaining) - post marketing surveillance $ +100 million Register with FDA / MCC (years)

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Alternative Drugs Vitamins Minerals Cholesterol vaporises Tissue salts NO RESEARCH NO EVIDENCE OF EFFICACY NO PRODUCTION CONTROL NO REGISTRATION PROCESS Trials done consistently show NO benefit eg. Folate, anti- oxidant vitamins

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Conspiracy Theory Doctors and Universities bribed / kick backs from pharmaceutical companies? Lack of patient trust? Only want natural treatment ( death?)

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Commonly Used Drugs Statins -reduce cholesterol - Zocor, Simvastatin, Lipitor, Aspavor, Crestor, Prava, Lescol primary prevention (at risk but currently asymptomatic) benefit in high risk persons or - secondary prevention (known with coronary artery disease) 30% reduction in future heart attack and stroke Aspirin - reduces blood stickiness primary (little benefit) or secondary prevention (25% ) ACE-I / ARB lower BP, improve heart failure - Prexum, Coversyl, Lisinopril, Zetomax, Pharmapres, Enalapril, Cozaar, Zartan, Diovan

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Commonly Used Drugs Beta Blockers reduce heart rate (angina) and BP, heart failure - Concor, Bilocor, Bisocor, Carloc, Dilatrend Calcium Channel blockers reduce heart rate and BP - Verahexal, Calcicard, Ravamil, Amloc, Norvasc, Zildem

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New Comers Coralin reduces heart rate without decreasing BP and no BB side effects (lethargy, impotence) - angina and heart failure Dabigatran thins blood like Warfarin but no INR (blood) testing needed - atrial fibrillation

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Guideline recommendations for BP goals

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Combination therapy needed to achieve target SBP goals INVEST; data on file. ALLHAT Collaborative Research Group. JAMA 2002; 288: 2981-97. Brenner BM, et al. N Engl J Med 2001; 345: 861-9. Lewis EJ, et al. N Engl J Med 2001; 345: 851-60. Adapted from Bakris GL, et al. Am J Kidney Dis 2000; 36: 646-61. Number of antihypertensive drugs Trial/SBP achieved INVEST (136mmHg) ALLHAT (138mmHg) IDNT (138mmHg) RENAAL (141mmHg) UKPDS (144mmHg) ABCD (132mmHg) MDRD (132mmHg) HOT (138mmHg) AASK (128mmHg) 1234

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Hypertension: a risk factor for cardiovascular morbidity and mortality Kannel WB. JAMA 1996; 275: 1571-6. Risk ratio2.02.23.82.52.03.74.03.0 Excess risk22.711.69.13.84.95.310.44.2 Normal Hypertensiv e 50 40 30 20 10 0 Biennial age-adjusted rate per 1000 MenWomenMenWomenMenWomenMen Women Coronary artery disease Stroke Peripheral arterial disease Cardiac failure

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MRFIT: association of systolic BP and diabetes with cardiovascular risk Stamler J, et al. Diabetes Care 1993; 16: 434-44. Diabetic 0 50 100 150 200 250300