Author + information
- aDivision of Cardiovascular Medicine, Brigham & Women's Hospital, Boston, Massachusetts
- bHarvard T.H. Chan School of Public Health, Department of Health Policy and Management Center for Health Decision Science, Boston, Massachusetts
- ↵∗Reprint requests and correspondence:
Dr. Thomas Gaziano, Division of Cardiovascular Medicine, Brigham & Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115.
Those who have been involved in the care and management of patients with cardiovascular disease and in particular coronary heart disease have much to be thankful for. Over the past 5 decades, those living in high-income countries have seen age-adjusted death rates for ischemic heart disease decline by >1% to 2% per year each year (1,2).
The success in reducing age-adjusted mortality has been multifactorial. Studies reviewing changes in coronary heart disease mortality over time estimate that the reductions are equally shared between improvements in management of risk factors through primary prevention efforts and improvements in the care of acute events or afterwards in secondary prevention efforts (3,4). Through the work of basic scientists and large epidemiologic cohorts, we elucidated many of the risk factors associated with developing atherosclerosis (5). This led to efforts to reduce tobacco consumption through the warnings of the U.S. Surgeon General and other public policies, including taxation and restrictions in advertising. Guidelines for screening and prevention were put into place for hypertension and dyslipidemia. In addition, development of pharmaceuticals and devices for treating high-risk individuals played a significant role. In addition to prevention efforts, major advancements in acute management occurred simultaneously. Development of specialized coronary care units with trained nurses specialized in recognizing abnormal rhythms and deploying defibrillators appropriately improved case fatality significantly. Ultimately, large randomized controlled trials evaluating the effectiveness of aspirin, thrombolytics, beta-blockers, angiotensin converting enzyme inhibitors, and percutaneous interventions in acute coronary syndromes also improved mortality rates.
However, the results of many landmark trials have not always yielded the full, expected benefits of reductions in practice for multiple reasons. First, it can take up to 6 years from the publication of a clinical trial before a proven therapy becomes a recommendation in clinical guidelines (6). It can take up to 17 years from original publication before an intervention is accepted into full clinical practice (7,8). Even for therapies that make it into clinical practice guidelines, implementation of guidelines by providers is uneven (9). Although rates of appropriate use of medications for acute myocardial infarction (AMI) have significantly improved over time, institutional organization has limited health care facilities from achieving the full benefits of the most time-sensitive therapies, such as percutaneous coronary interventions and administration of thrombolytics. Also, poor initiation by providers (10) has limited the full benefit of some long-term therapies.
One reason for late adoption of new therapies by providers is the concern about the generalizability of trial findings to their patients and the long-term benefits of therapies. The generalizability to a wider population is a challenge, particularly to elderly patients who are often excluded from trials either due to their age itself as explicit pre-specified criteria or because they have a higher likelihood of having a comorbid condition that excludes them. However, given the concern for the amount of money spent in the last 6 months of life, these are exactly the type of patients about whom we want to know more. The additional challenges for those wanting to understand the long-term effects of interventions are 2-fold. First, for ethical considerations, if a therapy is proven effective early on, for reasons of beneficence, there is a strong motivation to stop the trial early to allow others to have benefit of the therapy. In addition, long duration of follow-up in trials could prove prohibitively expensive.
The paper by Bucholz et al. (11) in this issue of the Journal addresses both the issue of long-term benefits and the impact among the elderly. The authors provide evidence that not only is there improved survival for those age >65 years who receive acute management for acute coronary syndromes with aspirin, beta-blockers, and acute reperfusion therapy either by percutaneous coronary intervention or by thrombolytic medicine, but that the benefits persist through a follow-up period of 17 years. Also important for those receiving aspirin and beta-blockers was whether they received these medications at discharge, which is perhaps a major driver of the difference in benefit in this observational study, compared with some of the earlier trials where benefits did not continue to accrue.
The rates of compliance for preventive therapies are much lower, though. Thus, we need to examine why we have a much lower proportion of the population that is screened and treated (71%) for hypertension (12) and elevated low-density lipoprotein cholesterol (13) (70%), when compared with compliance with AMI management of >95%. Certainly having the AMI therapies as part of the Centers for Medicare & Medicaid Services quality metrics has helped. Perhaps, having more preventive measures as part of risk-based contracts, such as in accountable care organizations, will help.
Showing the potential benefits of speeding up time from knowledge of acute therapies to full implementation of them may have impact on this process in the United States for other preventive therapies. Also, improving guideline-based therapies particularly for the management of AMI will most likely have its greatest immediate impact globally. The U.S. adoption rate of these therapies in AMI are >95% in most cases but are much lower in low- and middle-income countries, as highlighted by Bucholz et al. (11). In 2011, the United Nations set forth a target of reducing the 4 major noncommunicable diseases by 25% by 2025. Cardiovascular disease alone represents more than one-half of these deaths and is the leading cause of death globally. In response, the World Health Organization set specific targets on conditions and risk factors and changes in the health systems structure in order to achieve the goals. Although many of the targets were risk factor based, others included health system efforts to improve medical treatment of those at high risk for cardiovascular disease mortality. Although many countries are not currently providing percutaneous coronary interventions for the vast majority of the population, they are providing all of the other acute myocardial infarction therapies. Knowledge that timely and ready access to all other treatments can have both immediate and long-term benefits could go a long way to achieving the goal.
↵∗ Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology.
Dr. Gaziano has received grant funding from the National Heart, Lung, and Blood Institute for research on cost-effectiveness of cardiovascular disease prevention in the United States and South Africa; and has served as an advisor to the Healthy Heart Africa program sponsored by AstraZeneca.
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