THE NEW ZEALAND MEDICAL JOURNAL Vol 116 No 1185

ISSN 1175 8716

Secondary prevention in coronary artery disease patients in South Auckland: moving targets and the current treatment gap Seifeddin El-Jack and Andrew Kerr Abstract Aim To assess secondary prevention parameters in patients with coronary artery disease (CAD) and correlate them with evolving treatment targets. Methods We audited baseline and current secondary prevention parameters in consecutive patients with established CAD who were identified retrospectively after an acute coronary syndrome (n = 48), recent coronary artery bypass grafting (CABG, n = 50), or remote CABG (n = 49). Results Statins were used by 71% of the whole group and 80% of those whose total cholesterol (TC) levels exceeded the contemporaneous PHARMAC cut-off point for statin funding. Thirty seven per cent failed to achieve the New Zealand Heart Foundation (NZHF) target TC of 3–5 mmol/l current at the time, and 55% exceeded the National Cholesterol Education Programme and 2002 NZHF Interim Consensus Statement target of low density lipoprotein (LDL) 140/90 mmHg, 12% were smokers and 7% not on aspirin. A minority of patients were on ACE inhibitors (34%) and beta blockers (45%). Only 30% were non-smokers, on aspirin and met TC and BP targets. Conclusions Risk-factor management is sub-optimal in a significant percentage of secondary prevention patients. Improved statin availability in New Zealand subsequent to this audit creates the opportunity to reduce the treatment gap. A wealth of clinical-trial and epidemiological data supports the utility of lifestyle modification, smoking cessation, anti-hypertensive and lipid-lowering therapy, antiplatelet therapy and beta blockade in secondary prevention of coronary artery disease (CAD).1–4 Disappointingly, international and local studies have demonstrated a significant disparity between ideal secondary prevention and the clinical reality.5–12 The reasons for this ‘treatment gap’ are multifactorial. The 1996 New Zealand Heart Foundation (NZHF) Guidelines,13 current at the time of this audit, recommended that lipid-lowering strategies are instigated in patients with proven CAD and total cholesterol (TC) =5.5 mmol/l, aiming for target TC of 3–5 mmol/l. In December 1998 the New Zealand Government’s pharmaceutical watchdog, PHARMAC, adopted this level as a cut-off point for funding statins. Following revascularisation (coronary artery bypass grafting (CABG) or percutaneous coronary intervention), the cut-off point for funding therapy was TC =4.5 mmol/l. More recently, the European Societies Guidelines proposed a target low-density lipoprotein (LDL)