Physicians slow to prescribe newer heart drugs

An analysis of the treatment received by more than 100,000 heart patients has shown that physicians' prescription practices for drugs proven effective for treating heart disease has shown steady improvement over the past three years, cardiologists at the Duke Clinical Research Institute (DCRI) have concluded.

However, they emphasized there is much room for improvement, especially in the prescription of newer heart drugs.

Use of newer medications has lagged behind that of older and more established medications, they concluded. Also, lagging has been physicians' practice of giving advice to patients upon discharge from the hospital for such behavioral modifications such as smoking cessation and diet control, said the researchers.

The overall adherence to recommended medications rose from 71 percent at the beginning of the analysis in 2002 to 81.5 percent by the end of 2004, found the researchers. The use of the older drug aspirin, for example, was consistently prescribed to more than 96 percent of heart patients, while newer drugs such as clopidogrel or glycoprotein IIb/IIIa inhibitors were consistently prescribed less than 75 percent of the time.

The researchers said that a usage rate of 95 percent or higher for the new drugs would represent a successful adherence to the guidelines.

"The good news is that we have made substantial improvements in making sure that heart patients are receiving proven medications," said Duke cardiologist Rajendra Mehta, M.D., who presented the results of the analysis Nov. 14, 2005, at the annual scientific sessions of the American Heart Association (AHA) in Dallas.

"The trends in treatment practices are very encouraging," Mehta continued. "However, there is still much work to be done, especially in improving the usage rates of some of the newer medications. It appears that physicians have been slow to incorporate the latest recommendations into their routine practice."

The researchers analyzed how 113,595 patients were treated at 434 U.S. hospitals as a part of a national effort to improve the outcomes of patients with heart disease. They monitored the use of specific drugs and physician recommendations – both while in the hospital and at discharge -- that have been established as national guidelines by the American College of Cardiology (ACC) and the AHA.

For the analysis, Mehta drew on the database of a national quality improvement initiative known as CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC and AHA Guidelines). CRUSADE maintains a national registry of data collected from more than 400 hospitals nationwide and then reports back to each hospital every three months on their adherence to the guidelines.

The guidelines serve as a national model for optimal care of patients who arrive at the hospital with symptoms of a possible heart attack, such as chest pain (unstable angina), irregular readings on an electrocardiograph or elevated chemical markers of cell death.

The guidelines -- adopted after large-scale clinical trials demonstrated the effectiveness of specific therapies in saving lives -- focus on giving suspected heart attack patients anti-platelet medications, heparin, glycoprotein IIb/IIIa inhibitors (clot inhibitors) or beta-blockers within the first 24 hours of admission. The guidelines also call for prescribing such drugs as aspirin, beta-blockers, ACE inhibitors or statins after discharge, as well as recommendations for cardiac rehabilitation, smoking cessation and dietary modification.

"We found that most of the hospitals participating in CRUSADE have demonstrated substantial improvements in their care of heart patients," said Duke cardiologist E. Magnus Ohman, M.D., who also serves as CRUSADE executive chairman. "We hope that these promising results will motivate more hospitals to participate in quality improvement programs like CRUSADE or develop their own programs that adhere to the ACC/AHA guidelines."

Some of the specific trends from 2002 to 2004 follow:

• Beta Blockers – In hospital usage improved from 76 percent to 88 percent; outpatient usage improved from 81 percent to 89 percent
• Aspirin – In-hospital rates improved from 92 percent to 97 percent; outpatient usage rose from 93 percent to 96 percent.
• Clopidogrel (a newer agent that prevents platelets from clumping) – In-hospital rates rose from 36 percent to 54 percent, while outpatient usage rose from 50 percent to 72 percent.
• Glycoprotein IIb/IIIa inhibitors (a newer clot inhibitor used only in hospital) improved from 33 percent to 47 percent.
• Dietary modification – Improved from 66 percent to 83 percent.
• Smoking cessation – Improved from 59 percent to 85 percent.
• Cardiac rehabilitation improved from 37 percent to 65 percent.

DCRI researchers reported at last year's AHA meeting (will insert link) that adherence to the guidelines measured by CRUSADE is definitely linked to an improvement in outcomes. They reported that over time, mortality risks rose by 3.1 percent at hospitals whose adherence declined, while the mortality risks declined by 37 percent over the same time period among hospitals whose care patterns were most improved.

CRUSADE is coordinated by the DCRI. It is funded by Schering-Plough Corp, Kenilworth, N.J., with addition funding from the Bristol-Meyers Squibb/Sanofi Pharmaceuticals Partnership, NY, and Millennium Pharmaceuticals, Cambridge, Mass. Mehta and Ohman have no financial interests in any of the sponsors.