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Coronary heart disease secondary prevention
Journal Watch n 578
Rajeev Gupta, MD, PhD*,†; Shiva Ahuja, MDS†
News and Views n
* Department of Medicine, Fortis Escorts Hospital, Jaipur, India Jaipur Heart Watch Foundation, Jaipur, India.
†
580
Forthcoming Events n 583
Instruction to Contributors n 585
Abstract
n Introduction
Coronary heart disease (CHD) is an important public health problem in India and the most important cause of death. Morbidity and mortality in patients with established CHD can be prevented by lifelong adoption of healthy lifestyles and appropriate drug therapy. However, adherence to both these is very low and studies have reported less than 10–20% adherence at 5–6 years after diagnosis. International guidelines advise that cessation of smoking and tobacco use and promotion of physical activity and healthy diet are important. Rational drug therapy in patients with established CHD include aspirin, statins, beta blockers and angiotensin converting enzyme inhibitors as indicated. All physicians at primary, secondary as well as tertiary care must advise these strategies and ensure adherence.
Key Words •
Cardiovascular disease
•
Secondary prevention
•
Aspirin
•
Beta blockers
•
Statins
•
ACE inhibitors
Epidemiological data suggests that India is host to 30–40 million patients with coronary heart disease (CHD) and the prevalence is increasing.1 This is also the largest cause of 2 mortality in the country. Unfortunately, the diagnosis and management of CHD in the country is not standardized and follow-up mechanisms are poor.3,4 This is due to weak public and private healthcare systems for chronic disease management and lack of focus on prevention at the level of 4 primary, secondary and tertiary care. Innovative strategies to provide evidence-based therapies to all patients using guidelines, appropriate treatment delivery mechanisms, and improve and sustain adherence to these therapies are required. National societies such as the Association of Physicians of India (API), Cardiological Society of India (CSI) and others as well as medical journals have an 5 important role to play in this regard. There are five levels of prevention of CHD defined by the 6 World Health Organization (WHO). Primordial prevention deals with prevention of risk factors using population wide strategies to promote physical activity, tobacco and smoking cessation, and dietary fat, salt and alcohol control. This strategy leads to reduction of multiple cardiovascular risk factors and is the most cost-effective strategy when delivered appropriately. Primary prevention is control of major cardiovascular risk factors such as high total and LDL cholesterol, high blood pressure, the metabolic syndrome and diabetes. These strategies can lead to prevention of acute coronary events and delayed development of CHD. Secondary prevention deals with control of risk factors and appropriate
Received: 08-08-13; Revised: 17-02-14; Accepted: 02-03-14 Disclosures: This article has not received any funding and has no vested commercial interest Acknowledgements: None
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J. Preventive Cardiology Vol. 3
No. 4
May 2014
549
Gupta R, et al
pharmacotherapy in patients with established chronic CHD or after an acute coronary event. This strategy is the most effective strategy in reducing the number of cardiovascular events in CHD patients. The results of this approach are immediate and this is the “low-hanging fruit” in strategy to control CHD mortality. Tertiary prevention deals with use of advanced technologies (percutaneous interventions, coronary bypass surgery) in management of CHD, and quaternary prevention is focused on prevention of overuse of diagnostic procedures, medications and interventions.
at secondary practices and primary care.12 Two large community based studies, the Prospective Urban Rural 13 Epidemiology study (PURE) and Andhra Pradesh Rural 14 Health Initiative (APRHI) have reported patient-level use of secondary prevention therapies. In both, a very low community-based use of statins, beta blockers, ACE inhibitors as well as aspirin was observed. However, association of use of evidence therapies, adherence to such therapies (particularly drug use) and outcomes has not been reported in studies from India.
n Practice patterns in chronic CHD management
n Management recommendations for secondary
in India In India only limited epidemiological studies evaluated practice patterns in acute or chronic CHD settings and none has focused on compliance. The CREATE Registry7 enrolled 20,468 successive patients of acute coronary syndromes in 89 hospitals in India. Use of evidence based therapies in ST elevation myocardial infarction (STEMI) vs. non-NSTEMI was variable. Aspirin use was in 98.2% vs. 97.4%, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in 60.5% vs. 51.2%, beta blockers in 57.5% vs. 61.9%, lipid lowering drugs in 50.8% vs. 53.9%, respectively. OASIS-2 study8 reported 2-year mortality following an acute coronary syndrome (ACS) in some Indian hospitals and compared with international data. Use of evidence based therapies was low and the 2-year mortality was the highest in India due to low use of therapies. The Kerala Acute Coronary Syndrome (KACS) registry reported data on use of various cardiovascular drug therapies in 25,748 patients enrolled from 2007–2009 in 125 hospitals in Kerala.9 Use of discharge medications was suboptimal with aspirin in 76.4%, clopidogrel in 79.4%, beta-blockers in 62.7%, statins in 70.1%, ACE inhibitors or ARBs in 25.5% and nitrates in 75.1%. To identify practice patterns in secondary prevention, WHO-PREMISE study10 was conducted in eight middleand low-income countries including India and reported low use of secondary prevention therapies in stable CHD patients (n = 8483). In India (n = 932) use of aspirin was 94%, beta blockers in 46%, ACE inhibitors in 45% and statins in 38% and was much lower than in large international registries. In another prospective survey in 50 selected cities among 134 primary care physicians use of evidence based therapies was low in outpatients with stable CHD (n = 406),11 aspirin was prescribed in 83%, beta blockers in 53%, ACE inhibitors in 15% and statins in 69%. A study of prescription patterns in stable CHD patients among cardiologists, general physicians and primary care physicians reported a low use of evidence-based therapies 550
prevention There has been a decline in CHD incidence in most high 15 income countries. Many factors have contributed including: (1) Primary prevention through risk factor reduction by public health measures such as reduction in smoking and dietary change, and clinical approaches such as blood pressure control and lipid management; (2) Modern care for acute coronary syndromes including emergency services, coronary care units and revascularization strategies; and (3) Secondary prevention in those with known CHD including revascularization, medications and lifestyle approaches.
Coronary heart disease secondary prevention
care, secondary care or tertiary care need to increase the use of widely available secondary preventive measures recommended by guideline. Barriers to adherence need to be identified and overcome (Table 1). It is important to teach patients the importance of long-term use of these lifesaving drugs with improvement to adherence to therapies23 and to work with non-physician healthcare workers to help long-term compliance and care of patients with proven CHD. Increasing prescription of the life saving secondary prevention therapies: lifestyle and drugs are crucial, but more important is improvement of adherence to therapies. Components and goals of secondary prevention program have been summarized in Table 2 and Table 3 . These are modified from the ACC, AHA, ESC and WHO reports as previous Indian guidelines5 are modified from them only. No large outcome studies that can guide secondary prevention exist in India. Use of these modified versions is being evaluated in a pilot clinical trial—multicentre SPREAD study—in different regions of India.24 It is recommended that these should be used pragmatically in the Indian context.
A variety of programs have been developed to improve 25 providers’ and patients’ adherence to guidelines. In USA a Chronic Care Model has been proposed with six 26 components. This model is an integration of multiple policy elements and includes: (1) A shift in emphasis in CVD management from hospitalized to ambulatory care, (2) Redesign of the healthcare delivery system from an acute to a chronic care system, (3) Development of decision support systems and specialty care programs, (4) Clinical information systems with reminders for long-term follow-up of patients, (5) The involvement of community resources to support the patients, and (6) Development and use of patient self management support tools, including monitoring devices, risk-behavior modification aids, medication adherence reminders, overthe-counter drugs and support systems. Although this program has been developed to provide chronic care for USA, the steps are relevant to India where a similar fragmented healthcare system exists. Each of the component needs further research to identify contextspecific recommendations.
Table 1: Evidence based strategies for improving patient adherence to medications Strategy Identify poor adherence
Examples Look for markers of non-adherence, e.g., missed appointments (no shows), lack of response to medications, missed refills
Ask about barriers to adherence without being confrontational
Ask about beliefs of patients, use of alternative medications, etc.
Ask about value of the regimen and the effect of adherence
Patient beliefs and financial gains are important components to address
Elicit patients’ feelings about ability to follow regimen
Factors that influence decision making and financial considerations
Design supports to promote adherence
Individual and family based support systems
Provide simple clear instructions and simplify the regimen as much as possible
Nurse and technician based support at the time of hospital discharge
The British Quality Outcomes Framework (QOF) initiative emphasizes continued surveillance and target oriented 21 control of cardiovascular risk factors. Combination of lifestyle changes with aspirin, beta-blockers, statins and ACE inhibitors in all patients with established CHD can reduce two-year cardiovascular mortality from 8% to 2.3%.22
Encourage the use of medication system
Develop a customized medication system
Listen to the patient and customize the regimen in accordance to patients’ wishes
Dosage scheduling and meal times, especially in India
Obtain help form family members, friends and community services
Family support is crucial in India
Reinforce desirable behavior and results when appropriate
Social networking
Secondary prevention is a powerful strategy to decrease 15 cardiovascular mortality. Despite the availability of lowcost and effective pharmacological interventions in India, there are significant gaps in secondary prevention of CVD in urban and rural communities as reported above. All physicians who see patients with CHD, whether in primary
Consider more “suitable” medicines when non-adherence appears likely
Medications with long half-lives, depot (ER) medications, transdermal medications
Use of periodic reinforcements
Pharmacy based interventions, health care workers’ visits, trans-telephonic messaging, internet based strategies
Guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA),16,17 European Society of Cardiology (ESC),18 World Health 19 Organization (WHO) , etc. recommend that all healthcare professionals involved in care of CHD patients should impart lifestyle advise and medical therapy to patients and these should be continued indefinitely. The 2007 ACC 20 guidelines on standards of care for rehabilitation call for universal use of smoking cessation; increased physical activity; increased dietary fruits, vegetables and nuts; and reduced dietary fat; stress management; and drug therapy that includes aspirin, statins, beta blockers and angiotensin converting enzyme (ACE) inhibitors.
J. Preventive Cardiology Vol. 3
No. 4
May 2014
J. Preventive Cardiology Vol. 3
No. 4
May 2014
551
Gupta R, et al
pharmacotherapy in patients with established chronic CHD or after an acute coronary event. This strategy is the most effective strategy in reducing the number of cardiovascular events in CHD patients. The results of this approach are immediate and this is the “low-hanging fruit” in strategy to control CHD mortality. Tertiary prevention deals with use of advanced technologies (percutaneous interventions, coronary bypass surgery) in management of CHD, and quaternary prevention is focused on prevention of overuse of diagnostic procedures, medications and interventions.
at secondary practices and primary care.12 Two large community based studies, the Prospective Urban Rural 13 Epidemiology study (PURE) and Andhra Pradesh Rural 14 Health Initiative (APRHI) have reported patient-level use of secondary prevention therapies. In both, a very low community-based use of statins, beta blockers, ACE inhibitors as well as aspirin was observed. However, association of use of evidence therapies, adherence to such therapies (particularly drug use) and outcomes has not been reported in studies from India.
n Practice patterns in chronic CHD management
n Management recommendations for secondary
in India In India only limited epidemiological studies evaluated practice patterns in acute or chronic CHD settings and none has focused on compliance. The CREATE Registry7 enrolled 20,468 successive patients of acute coronary syndromes in 89 hospitals in India. Use of evidence based therapies in ST elevation myocardial infarction (STEMI) vs. non-NSTEMI was variable. Aspirin use was in 98.2% vs. 97.4%, angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in 60.5% vs. 51.2%, beta blockers in 57.5% vs. 61.9%, lipid lowering drugs in 50.8% vs. 53.9%, respectively. OASIS-2 study8 reported 2-year mortality following an acute coronary syndrome (ACS) in some Indian hospitals and compared with international data. Use of evidence based therapies was low and the 2-year mortality was the highest in India due to low use of therapies. The Kerala Acute Coronary Syndrome (KACS) registry reported data on use of various cardiovascular drug therapies in 25,748 patients enrolled from 2007–2009 in 125 hospitals in Kerala.9 Use of discharge medications was suboptimal with aspirin in 76.4%, clopidogrel in 79.4%, beta-blockers in 62.7%, statins in 70.1%, ACE inhibitors or ARBs in 25.5% and nitrates in 75.1%. To identify practice patterns in secondary prevention, WHO-PREMISE study10 was conducted in eight middleand low-income countries including India and reported low use of secondary prevention therapies in stable CHD patients (n = 8483). In India (n = 932) use of aspirin was 94%, beta blockers in 46%, ACE inhibitors in 45% and statins in 38% and was much lower than in large international registries. In another prospective survey in 50 selected cities among 134 primary care physicians use of evidence based therapies was low in outpatients with stable CHD (n = 406),11 aspirin was prescribed in 83%, beta blockers in 53%, ACE inhibitors in 15% and statins in 69%. A study of prescription patterns in stable CHD patients among cardiologists, general physicians and primary care physicians reported a low use of evidence-based therapies 550
prevention There has been a decline in CHD incidence in most high 15 income countries. Many factors have contributed including: (1) Primary prevention through risk factor reduction by public health measures such as reduction in smoking and dietary change, and clinical approaches such as blood pressure control and lipid management; (2) Modern care for acute coronary syndromes including emergency services, coronary care units and revascularization strategies; and (3) Secondary prevention in those with known CHD including revascularization, medications and lifestyle approaches.
Coronary heart disease secondary prevention
care, secondary care or tertiary care need to increase the use of widely available secondary preventive measures recommended by guideline. Barriers to adherence need to be identified and overcome (Table 1). It is important to teach patients the importance of long-term use of these lifesaving drugs with improvement to adherence to therapies23 and to work with non-physician healthcare workers to help long-term compliance and care of patients with proven CHD. Increasing prescription of the life saving secondary prevention therapies: lifestyle and drugs are crucial, but more important is improvement of adherence to therapies. Components and goals of secondary prevention program have been summarized in Table 2 and Table 3 . These are modified from the ACC, AHA, ESC and WHO reports as previous Indian guidelines5 are modified from them only. No large outcome studies that can guide secondary prevention exist in India. Use of these modified versions is being evaluated in a pilot clinical trial—multicentre SPREAD study—in different regions of India.24 It is recommended that these should be used pragmatically in the Indian context.
A variety of programs have been developed to improve 25 providers’ and patients’ adherence to guidelines. In USA a Chronic Care Model has been proposed with six 26 components. This model is an integration of multiple policy elements and includes: (1) A shift in emphasis in CVD management from hospitalized to ambulatory care, (2) Redesign of the healthcare delivery system from an acute to a chronic care system, (3) Development of decision support systems and specialty care programs, (4) Clinical information systems with reminders for long-term follow-up of patients, (5) The involvement of community resources to support the patients, and (6) Development and use of patient self management support tools, including monitoring devices, risk-behavior modification aids, medication adherence reminders, overthe-counter drugs and support systems. Although this program has been developed to provide chronic care for USA, the steps are relevant to India where a similar fragmented healthcare system exists. Each of the component needs further research to identify contextspecific recommendations.
Table 1: Evidence based strategies for improving patient adherence to medications Strategy Identify poor adherence
Examples Look for markers of non-adherence, e.g., missed appointments (no shows), lack of response to medications, missed refills
Ask about barriers to adherence without being confrontational
Ask about beliefs of patients, use of alternative medications, etc.
Ask about value of the regimen and the effect of adherence
Patient beliefs and financial gains are important components to address
Elicit patients’ feelings about ability to follow regimen
Factors that influence decision making and financial considerations
Design supports to promote adherence
Individual and family based support systems
Provide simple clear instructions and simplify the regimen as much as possible
Nurse and technician based support at the time of hospital discharge
The British Quality Outcomes Framework (QOF) initiative emphasizes continued surveillance and target oriented 21 control of cardiovascular risk factors. Combination of lifestyle changes with aspirin, beta-blockers, statins and ACE inhibitors in all patients with established CHD can reduce two-year cardiovascular mortality from 8% to 2.3%.22
Encourage the use of medication system
Develop a customized medication system
Listen to the patient and customize the regimen in accordance to patients’ wishes
Dosage scheduling and meal times, especially in India
Obtain help form family members, friends and community services
Family support is crucial in India
Reinforce desirable behavior and results when appropriate
Social networking
Secondary prevention is a powerful strategy to decrease 15 cardiovascular mortality. Despite the availability of lowcost and effective pharmacological interventions in India, there are significant gaps in secondary prevention of CVD in urban and rural communities as reported above. All physicians who see patients with CHD, whether in primary
Consider more “suitable” medicines when non-adherence appears likely
Medications with long half-lives, depot (ER) medications, transdermal medications
Use of periodic reinforcements
Pharmacy based interventions, health care workers’ visits, trans-telephonic messaging, internet based strategies
Guidelines from the American College of Cardiology (ACC) and American Heart Association (AHA),16,17 European Society of Cardiology (ESC),18 World Health 19 Organization (WHO) , etc. recommend that all healthcare professionals involved in care of CHD patients should impart lifestyle advise and medical therapy to patients and these should be continued indefinitely. The 2007 ACC 20 guidelines on standards of care for rehabilitation call for universal use of smoking cessation; increased physical activity; increased dietary fruits, vegetables and nuts; and reduced dietary fat; stress management; and drug therapy that includes aspirin, statins, beta blockers and angiotensin converting enzyme (ACE) inhibitors.
J. Preventive Cardiology Vol. 3
No. 4
May 2014
J. Preventive Cardiology Vol. 3
No. 4
May 2014
551
Gupta R, et al
Coronary heart disease secondary prevention
Table 2: Secondary prevention: Control of risk factors Goals Smoking/tobacco use • Complete cessation • No exposure to environmental tobacco smoke Blood pressure control •