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.
- Fenofibrate – These 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
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