quality use of cardiovascular medication dr mark abelson

14
QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Upload: agnes-barber

Post on 26-Dec-2015

232 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

QUALITY USE OF CARDIOVASCULAR MEDICATION

Dr Mark Abelson

Page 2: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

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

Page 3: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

• Drug launched (5 years patent remaining)- post marketing surveillance

• $ +100 million • Register with FDA / MCC (years)

Page 4: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

“Alternative” Drugs• Vitamins• Minerals• Cholesterol vaporises• Tissue salts NO RESEARCHNO EVIDENCE OF EFFICACYNO PRODUCTION CONTROLNO REGISTRATION PROCESS

Trials done consistently show NO benefit eg. Folate, anti-oxidant vitamins

Page 5: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Conspiracy Theory

• Doctors and Universities – bribed / kick backs from pharmaceutical companies?

• Lack of patient trust?• Only want “natural” treatment ( death?)

Page 6: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

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

Page 7: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

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

Page 8: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

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

Page 9: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Guideline recommendations for BP goals

– <140/90mmHg for essential hypertension– <130/80mmHg for hypertensive patients with

diabetes

• Most patients with hypertension will require two or more antihypertensive agents to achieve BP goal

Guidelines Committee. J Hypertens 2003; 21: 1011-53.Guidelines Committee. J Hypertens 2003; 21: 1011-53.Chobanian AV, et al. JAMA 2003; 289: 2560-72.Chobanian AV, et al. JAMA 2003; 289: 2560-72.

*ESH/ESC: European Society of Hypertension/European Society of Cardiology*ESH/ESC: European Society of Hypertension/European Society of Cardiology

**JNC 7: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, seventh **JNC 7: Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, seventh reportreport

Page 10: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Combination therapy needed to achieve target SBP goals

INVEST; data on file.INVEST; data on file.ALLHAT Collaborative Research Group. JAMA 2002; 288: 2981-97.ALLHAT Collaborative Research Group. JAMA 2002; 288: 2981-97. Brenner BM, et al. N Engl J Med 2001; 345: 861-9.Brenner BM, et al. N Engl J Med 2001; 345: 861-9.Lewis EJ, et al. N Engl J Med 2001; 345: 851-60.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.Adapted from Bakris GL, et al. Am J Kidney Dis 2000; 36: 646-61.

Number of antihypertensive drugsNumber of antihypertensive drugs

Trial/SBP achievedTrial/SBP achieved

INVEST (136mmHg)INVEST (136mmHg)

ALLHAT (138mmHg)ALLHAT (138mmHg)

IDNT (138mmHg)IDNT (138mmHg)

RENAAL (141mmHg)RENAAL (141mmHg)

UKPDS (144mmHg)UKPDS (144mmHg)

ABCD (132mmHg)ABCD (132mmHg)

MDRD (132mmHg)MDRD (132mmHg)

HOT (138mmHg)HOT (138mmHg)

AASK (128mmHg)AASK (128mmHg)

1 2 3 4

Page 11: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Hypertension: a risk factor forcardiovascular morbidity and mortality

Kannel WB. JAMA 1996; 275: 1571-6.

Risk ratioRisk ratio 2.02.0 2.22.2 3.83.8 2.52.5 2.02.0 3.73.7 4.04.0 3.03.0

Excess riskExcess risk 22.722.7 11.611.6 9.19.1 3.83.8 4.94.9 5.35.3 10.410.4 4.24.2

NormalHypertensive

5050

4040

3030

2020

1010

00

Bien

nial

age

-adj

uste

dBi

enni

al a

ge-a

djus

ted

rate

per

100

0ra

te p

er 1

000

MenWomen MenWomen MenWomen MenWomen

Coronary artery disease Stroke

Peripheralarterial disease

Cardiac failure

Page 12: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

MRFIT: association of systolic BP and diabetes with cardiovascular risk

Stamler J, et al. Diabetes Care 1993; 16: 434-44.Stamler J, et al. Diabetes Care 1993; 16: 434-44.

DiabeticDiabetic

00

5050

100100

150150

200200

250250

300300

<120<120 120-139120-139 140-159140-159 160-179160-179 180-199180-199 200+200+

Non-diabeticNon-diabetic

CVD

dea

ths

CVD

dea

ths

per

10,

000

pers

on-y

ears

per

10,

000

pers

on-y

ears

Systolic BP (mmHg)Systolic BP (mmHg)

Page 13: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson

Early morning BP surge coincides with peak incidences of stroke and myocardial infarction

McInnes G. J Am Soc Hypertens 2008;2:S16–22.

Time of day

180

160

140

120

100

80

60

40

20

0

18.00 0.00 06.00 12.00

50

45

40

35

30

25

20

15

10

5

0

Cere

brov

ascu

lar e

vent

s(p

er 2

hou

rs)

MI (

per h

our)

Stroke (n=1,167)

MI (n=2,999) Early morningBP surge

Page 14: QUALITY USE OF CARDIOVASCULAR MEDICATION Dr Mark Abelson