Shortfalls in Secondary Prevention Represent a "Colossal Human Tragedy"

Shortfalls in Secondary Prevention Represent a "Colossal Human Tragedy"
It shouldn't come as a surprise, but an international epidemiological study shows large shortfalls in the use of established drugs for secondary prevention of coronary disease and stroke. The shortfalls are dramatically acute in poor countries, said Salim Yusuf, who presented the results of the Prospective Urban Rural Epidemiological (PURE) study at the ESC in Paris today. The paper was published simultaneously in the Lancet.

The PURE investigators enrolled 153,996 people in 13 countries at different levels of economic development. They identified 5650 people with a history of CHD and 2292 with a history of stroke and ascertained whether they were taking antiplatelet drugs, beta blockers, ACE inhibitors or ARBs, or statins. Antiplatelet drugs were used by 62% of patients in high-income countries compared with 8.8% in low-income countries. A similar pattern was observed with beta blockers (40% versus 9.7%), ACE inhibitors or ARBs (49.8% versus 5.2%) and statins (66.5% versus 3.3%).

The study is unique in that it is the first to examine the use of drugs for secondary prevention in the community. It appears to be the first study to seek an accurate assessment of the use of these drugs in the community. Previous studies have been hospital based or based on patients who are seeing a physician and who are therefore much more likely to have been offered treatment.

The investigators also found that drugs were more likely to be used in urban than in rural areas, though the difference was more pronounced in low-income countries. The economic status of the countries had a bigger effect on drug use than individual factors such as age, sex, education, or other risk factors. Among the study's many other findings, women and smokers had significantly lower rates of drug usage.

The results, said Yusuf, "represent a colossal human tragedy" caused by the "substantial underutilization of proven therapies." The Lancet authors concluded that "efforts to increase the use of effective and inexpensive drugs for prevention of cardiovascular disease are urgently needed, and would substantially reduce disease burden within a few years."

Here is the press release from the Lancet:

International study reveals substantial underuse of effective low-cost drug treatments for heart disease and stroke (The PURE Study)

A global study reveals that inexpensive drug treatments for cardiovascular disease that have been proven to save lives are substantially underused worldwide. Around 60% of individuals with heart disease and up to half of patients who have had a stroke might not be taking any of the four effective drug types*. Underuse of these beneficial treatments is especially common in low-income countries where about 80% of patients reported receiving none of these essential drugs.

The largest study of its kind to date, presented at The European Society of Cardiology Congress in Paris, France, and published simultaneously Online First in The Lancet, suggests that improvements in the use of these low-cost drugs could substantially reduce global cardiovascular disease within just a few years.

“Even in well developed health-care systems many patients are not receiving the best secondary prevention treatment, despite a wealth of preventative guidelines, continuing medical education, and revalidation programmes”, explains Anthony Heagerty from The University of Manchester, Manchester, UK in an accompanying Comment.

Globally, cardiovascular disease affects more than 100 million people. Despite around 75% of the world’s heart disease and stroke burden occurring in low-income and middle-income countries, little is known about the actual use of preventive drug treatments in these communities.

The PURE study was designed to assess the use of four key secondary preventive and blood-pressure-lowering drugs in the community in three high-income, ten middle-income, and four low-income countries**. The study enrolled 153 996 adults from 628 rural and urban communities across five continents. 5650 participants reported a prior coronary heart disease event and 2292 a previous stroke.

Overall, the use of preventive drugs was low. Antiplatelet drugs (mainly aspirin) were taken by only a quarter of individuals with cardiovascular disease, ß-blockers by 17.4%, ACE inhibitors or ARBs by 19.5%, and statins by just 14.6%.

Drug use was highest in high income countries (where about two thirds of patients were taking antiplatelet drugs and statins, and about half of patients ß-blockers and ACE inhibitors or ARBs) and lowest in low-income countries (where less than 10% of patients used these proven therapies).

The authors point out: “Even the use of accessible and inexpensive treatments such as aspirin (the most commonly used antiplatelet drug) varied seven-fold between low-income and high-income countries but the use of statins varied 20-fold.”

The economic wealth of a country accounted for two thirds of the variation in drug use, with individual-related factors (such as age, sex, education, smoking, hypertension, and diabetes) affecting the rest.

According to the authors: “Improvements to the uptake of effective secondary prevention strategies are probably more feasible than lifestyle modifications in primary prevention (although both are desirable)…but this will require systematic programmes in most countries.”

In a Comment, Anthony Heagerty says: “In developing countries, the problems are more daunting and complex…Even in areas where cholesterol might be lower than in Europe or North America, the use of statins could reduce stroke and coronary artery disease. Education of doctors and patients must be a priority for governments. Partnership with industry, as employed in the fight against HIV, could reap immediate and valuable rewards where cheap generic drugs are not available.”

No comments:

Post a Comment