Coronary Heart Disease Medication Robert Hallworth Chair – Greater Manchester Non-Medical Prescribing Network Oldham Primary Care Trust
CHD - so who do we mean and what should we look at?
Established - post MI, CABG, ischaemic stroke / TIA, angina, AF, PVD
Raised cholesterol, obesity, smokers
Intervention + review based on current status, risk factors, existing treatment
Targets in the GMS contract
Case It is a busy day in your practice and you are sitting at your desk, legs up, leafing through a recent issue of Diversion, The Magazine for Physicians at Leisure . You come across an ad for Plavix, TM which states that this medication reduces the risk of cardiovascular events by 9% compared to aspirin. You wonder if you should be switching all your patients to Plavix. TM
Statin therapy reduces the relative risk of major events by one fifth (20%) for every 1mmol/L reduction in LDL cholesterol (but is there really a linear relationship?).
This is largely irrespective of the initial lipid profile or other presenting characteristics.
The absolute benefit relates chiefly to an individual's absolute risk of such events and to the absolute reduction in LDL cholesterol achieved.
Statins at established doses (e.g. simvastatin 40mg) can reduce LDL cholesterol by at least 1·5mmol/L in many patients, and hence would be expected to reduce the incidence of major vascular events by about one third.
The possibility that higher doses would result in clinically relevant adverse effects cannot be excluded.
Phase Z of the A to Z trial showed no difference in event rates between simvastatin 40mg od for 1 month followed by 80mg od compared to placebo for 4 months followed by simvastatin 20mg od. There were 3 cases of rhabdomyolysis in patients receiving 80mg simvastatin.
PROVE-IT compared pravastatin 40mg to atorvastatin 80mg. The primary endpoint was time to first of death, MI, re-hospitalisation for UA, revascularisation or stroke. 22.4% of patients in the atorvastatin arm had these events at 2 years compared to 26.3% in the pravastatin group .
IDEAL showed no difference in the primary endpoint of time to first coronary death, MI or resuscitated cardiac arrest between simvastatin or atorvastatin
Use a statin in patients with ACS de Lemos JA, et al. JAMA 2004; 292: 1307 16 Cannon CP, et al. N Engl J Med 2004; 350: 1495 504 Pedersen TR, et al. JAMA 2005; 294: 2437 45
Cholesterol measurements in the first few years of statin treatment may mislead
Galsziou P et al. Monitoring cholesterol levels: measurement error or true change? Ann Intern Med 2008; 148: 656-61
Health professionals should be wary of increasing a patient’s lipid-lowering treatment on the basis of a single cholesterol test if they are reasonably confident that the patient is taking the medication as prescribed.
HPS suggests: Up to 40mg simvastatin adverse effects = placebo
SEAS and ezetimibe: no benefits on CV endpoints, questions raised over cancer risk
Rossebo AB et al for the SEAS Investigators. Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis. N Engl J Med 2008; 359
It would seem sensible to use ezetimibe only with caution as there is no published evidence of its benefit on clinically important outcomes such as cardiovascular events and its long-term safety is unknown
“ The key message from ALLHAT is that what matters most is getting blood pressure controlled, and that this is overwhelmingly more important than the means. Combinations of several drugs will be required for most patients, and such an antihypertensive treatment cocktail should include a thiazide diuretic”
If on diuretic monitor K periodically (<4mmol/l give K-sparing diuretic)
Digoxin level (only if toxicity suspected or 1 week after adding or stopping interacting drug)
Discontinue if toxicity (usually >3ng/ml)
Also check potassium if toxicity suspected
Frequency of and risk factors for preventable medication-related hospital admissions
Leendertse AJ et al. Arch Intern Med. 2008; 168: 1890-1896
Medicines most frequently associated with the potentially preventable admissions included those affecting blood coagulation, NSAIDs, and antidiabetic drugs, with a total of 509 medication errors being identified in the 332 potentially preventable medicines-related admissions.