What your cardiologist (should have) learned last month

28 Mar

by Carolyn Thomas  @HeartSisters

After a bunch of top cardiologists got together in San Francisco recently for the annual American College of Cardiology scientific meetings, Debra Sherman and her team did a fine job summing up highlights for Reuters.*  One of their first take-home messages: some cardiologists believe that drug prescribing has gotten out of hand. 

“A number of leading heart doctors said eliminating certain drugs could potentially improve care without compromising treatment. Evidence is growing that some medications are not effective.”

For example, Dr. Micah Eimer, a Chicago cardiologist, told Reuters that a person who has had a heart attack typically leaves the hospital on a beta blocker drug to slow the heart, an ACE inhibitor to reduce blood pressure, clopidogrel and aspirin to thin the blood and prevent clots, and a statin to reduce cholesterol. But he warned:

“That’s a minimum of five medications, and each one has a proven mortality benefit. It’s practically malpractice if you don’t prescribe those.

“But we have no data on when it’s advantageous to take (patients) off.”

Dr. Richard Stein is a professor of medicine at New York University and spokesperson for the American Heart Association. He estimated the average patient with heart disease may take from seven to nine pills each day in order to control various risk factors including cholesterol, high blood pressure and diabetes. But, he said, it makes sense to be restrictive.

“Doctors should exclude pills that don’t critically help patient care. To live your life taking that many pills, the danger is you’ll stop taking the critical ones, because how many pills can you take several times a day?”

Dr. Harlan Krumholz, a Yale University professor of cardiology and public health, added that many patients are on many more drugs. He cited studies reporting that patients living with heart failure, for example – those whose hearts are too weak to pump blood efficiently – were prescribed an average of 12 drugs; some were on as many as 30! He explained:

“We are eager to add medicines and reluctant to take them away.

“So people accrue medications over time. And many drugs are prescribed widely, even though evidence they actually work is weak.”

One reason that doctors continue to prescribe drugs whose effectiveness evidence is “weak” is because of the excellent marketing work being done by pharmaceutical companies that manufacture these drugs. In fact, the 13 main classes of drugs used to treat various types of cardiovascular disease had total sales in the U.S. alone of almost $75 billion in 2011.

This is important to you if you have been prescribed one or more of the heart medications that came under scrutiny at the ACC conference that included:

  • Niacin – Unexpected serious side effects arose in a huge study of over 25,000 people of Merck’s long-acting niacin drug Tredaptive aimed at raising HDL (good) cholesterol. Patients had significantly more bleeding and a higher number of infections than researchers had expected. Because the drug had failed to prevent heart attacks, strokes and death in heart patients also taking drugs to lower LDL (bad) cholesterol, Merck said it would not seek U.S. approval and would stop selling it in the dozens of other countries where it was already available.
  • FenofibrateThese drugs apparently lower blood fats called triglycerides, but studies reported at the ACC conference failed to show any benefit of the top-selling branded drug TriCor in two separate studies.
  • Beta blockers – These drugs may be absolutely necessary for some patients, as NYU cardiologist Dr. Sripal Bangalore told Reuters, but they are “probably prescribed too widely and for too long a period of time.” Examining three distinct patient groups from a data registry of 44,000 patients, he said the drug did not reduce the risk of heart attack, stroke or death. Yet both American Heart Association and American College of Cardiology guidelines recommend heart attack survivors take beta blockers for at least three years. Those recommendations, several doctors at the ACC conference noted, are based on data collected two decades ago. But today, blocked arteries are cleared right away with angioplasty, and the patient is typically put on a statin to keep harmful plaque from building up within the artery walls. For those whose hearts are not badly damaged, beta blockers do not help. “We don’t know if they are providing benefit for one year or three years,” as Dr. Bangalore said.
  • Blood thinners –  These include drugs like Coumadin (warfarin) commonly used to treat some types of heart disease by preventing blood clots. Stanford School of Medicine cardiologist Dr. Robert Harrington told Reuters that some patients were at risk of bleeding when they were on more than one. “We’ve had recent trials where we’ve gone from one to two to three agents,” he said. “There’s got to be a way to start peeling away, and maybe it’s over a period of time, or as the clinical status changes.”

* Reporting by Debra Sherman with additional assistance from Rans Pierson, Bill Berkrot, Jilian Mincer, Martin Howell and Prudence Crowther

See also:

8 Responses to “What your cardiologist (should have) learned last month”

  1. Betsy March 31, 2013 at 5:08 am #

    Thanks alot for this update from ACC13; I’ve been reading about research linking statins with diabetes and other serious issues. We only have to look at deadly – yet approved and widely prescribed – drugs like Vioxx and Avandia and so many others to find alarming evidence of harm in some drugs, but these cardiologists quoted here are also looking at efficacy: do our heart drugs WORK to produce better outcomes? If not, why are they being ordered for us?

    Every doctor should read this.

    Like

    • Carolyn Thomas March 31, 2013 at 8:28 am #

      Why indeed? I like Kathleen’s motto (below): don’t take any drugs without a clear reason. Another disturbing reality is that those doctors who write treatment guidelines are too often on the payroll of the drug companies whose products they are recommending, as reported in the journal Archives of Internal Medicine: For example:

      “More than half of the doctors who wrote clinical practice guidelines in cardiology between 2004 and 2008 served as promotional speakers on behalf of industry, and a substantial number actually held stock in companies affected by the guidelines they wrote.”

      You can read more about physicians’ conflicts of interest in clinical practice guidelines here.

      Like

  2. Kathleen March 28, 2013 at 10:21 am #

    And these drugs become a form of Cardiology-By-The-Numbers.
    In 2009 I was pushing (again) for a coherent explanation for my abnormal EKGs and constellation of symptoms, as my HMO cardiologist rejected my suggestion of apical hypertrophic cardiomyopathy (AHC) as he had in 2006. He proposed beta blockers “just to see how you do.”

    I don’t take any drug without a clear reason, which he couldn’t offer, and so he made a point of entering into my medical record that I had refused his recommended beta blockers. You know: Non-compliant.

    It was Fall 2012, after a diagnosis of AHCM (finally) when another HMO cardiologist told me that beta blockers would be dangerous for me, as my heart rate is already so slow (40 at rest). And that frequent monitoring is critical for people with HCM, but beta blockers render treadmill stress tests just about useless.

    Like

    • Carolyn Thomas March 28, 2013 at 12:26 pm #

      Yours is a cautionary tale in which – depending on which doctor is doing the talking – a patient can hear two (or more) different messages, each from an “expert”. Good for you, Kathleen, for following your gut instinct to question any drugs being prescribed “without a clear reason”. I’ve talked to a number of heart patients with already low blood pressure being put on antihypertensives after their cardiac events – “because that’s what we do”.

      Like

      • Kathleen March 28, 2013 at 1:03 pm #

        That’s exactly what happened to my father! After his cardiac arrest a cardiologist (also sailing buddy) prescribed antihypertensives and he began passing out left, right and center.

        After one visit to the ER at the local teaching hospital, he began to see one of their best cardiologists as well. I went with him to one of those appointments and the nurse who took his blood pressure said, “Well, sir, according to this machine you are dead, but as that is clearly not the case I will find something else.” The med school cardiologist said that he did not understand why the other doc had my dad on antihypertensives, which might raise questions in someone other than my father. He ignored those of us who urged him to get off antihypertensives and continued to say that he was so lucky and his docs were “both just great guys.” And so he kept passing out. “Spells” he called them. Mom got to know all the local EMT people.

        The first doc didn’t stop the meds until Mom threw a fit in his office. You know: Hysterical Female. But he did stop, and without those meds Dad stopped having “spells.”

        Like

        • Carolyn Thomas March 28, 2013 at 1:37 pm #

          Yikes!

          Like

          • Linda Heitlauf April 1, 2013 at 5:01 am #

            I’m delighted to say my cardiologist is on-point with this discussion. We talked about the overuse of pharmacology in the treatment of heart disease at my check-up last week when he actually reduced my daily dose of beta blocker, Coreg, by half. Yay!

            Like

            • Carolyn Thomas April 1, 2013 at 6:19 am #

              Every patient should be having conversations with their cardiologists as you have just had, Linda! Thanks for this reminder.

              Like

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