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

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

“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

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

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

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

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

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: Chobanian AV, et al. JAMA 2003; 289: *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 report

Combination therapy needed to achieve target SBP goals INVEST; data on file. ALLHAT Collaborative Research Group. JAMA 2002; 288: Brenner BM, et al. N Engl J Med 2001; 345: Lewis EJ, et al. N Engl J Med 2001; 345: Adapted from Bakris GL, et al. Am J Kidney Dis 2000; 36: 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

Hypertension: a risk factor for cardiovascular morbidity and mortality Kannel WB. JAMA 1996; 275: Risk ratio Excess risk Normal Hypertensiv e Biennial age-adjusted rate per 1000 MenWomenMenWomenMenWomenMen Women Coronary artery disease Stroke Peripheral arterial disease Cardiac failure

MRFIT: association of systolic BP and diabetes with cardiovascular risk Stamler J, et al. Diabetes Care 1993; 16: Diabetic < Non-diabetic CVD deaths per 10,000 person-years Systolic BP (mmHg)

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 Cerebrovascular events (per 2 hours) MI (per hour) Stroke (n=1,167) MI (n=2,999) Early morning BP surge