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After 4S, CARE and LIPID--is evidence-based medicine being practised?
1Servicio Cardiologie, Hospital General Universitario, Valencia, Spain.
Insights
Major trials show statins reduce recurrent coronary events. However, a significant gap exists between evidence and practice in secondary prevention, with low statin use despite high cholesterol prevalence.
Area of Science:
- Cardiology
- Preventive Medicine
- Pharmacotherapy
Background:
- Landmark trials (4S, CARE, LIPID) demonstrated statin efficacy (simvastatin, pravastatin) in reducing recurrent coronary events in patients with established coronary heart disease (CHD).
- Benefits of statin therapy, including improved survival, were observed even in patients with 'normal' cholesterol levels, highlighting their utility in secondary CHD prevention.
- Despite strong evidence, recent surveys indicate a substantial gap between recommended and actual clinical practice in secondary CHD prevention.
Purpose of the Study:
- To assess the adherence to evidence-based guidelines for secondary prevention of coronary heart disease (CHD) in clinical practice.
- To identify the therapeutic gap in statin prescribing for patients with established CHD, particularly those with hypercholesterolemia or 'normal' cholesterol levels.
- To emphasize the need for improved collaboration and integrated care approaches to bridge the gap between scientific evidence and clinical practice in CHD prevention.
Main Methods:
- Review of findings from major clinical trials (4S, CARE, LIPID) evaluating statin therapy for secondary CHD prevention.
- Analysis of recent CHD prevention surveys conducted between 1994 and 1998 to assess prescribing patterns and treatment adherence.
- Comparison of evidence-based recommendations with actual clinical practice regarding statin use in post-coronary event patients.
Main Results:
- Statins (simvastatin, pravastatin) significantly reduce the risk of recurrent coronary events in patients with established CHD.
- A high prevalence of hypercholesterolemia was noted in patients post-hospital discharge and at 6 months after a coronary event.
- Low rates of statin prescribing were observed, indicating a significant therapeutic gap in secondary CHD prevention despite compelling evidence.
Conclusions:
- There is a critical need for an integrated approach involving hospital specialists, primary-care physicians, and patients to improve statin adherence.
- Evidence-based medicine for lowering cholesterol, even in patients with normal levels, is not being adequately translated into clinical practice for secondary CHD prevention.
- Addressing the identified therapeutic gap is crucial for optimizing outcomes and reducing recurrent cardiovascular events in high-risk patients.
Abstract:
Between 1994 and 1997, three major trials - 4S, CARE and LIPID - showed that simvastatin and pravastatin reduced the risk of a recurrent coronary event in patients with established coronary heart disease (CHD) [Scandinavian Simvastatin Survival Study (4S) Group. Lancet 1994;344:1383-89; Sacks FM et al. New Engl. J. Med. 1996;335: 1001-9; Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. New Engl. J. Med. 1998;339:1349-57]. The results of CARE and LIPID, with pravastatin, also showed that the benefits of improved survival extended to the majority of patients with CHD whose cholesterol levels were in the 'normal' range. Despite this compelling evidence, recent CHD prevention surveys between 1994 and 1998 have unveiled a wide therapeutic gap between scientific evidence and practice in the secondary prevention of CHD. These recent surveys revealed a high prevalence of hypercholesterolaemia in patients discharged from hospital and after 6 months following a coronary event, but low levels of statin prescribing in these patients. Of the minority of patients prescribed a statin by a consultant on discharge from hospital, nearly all were still receiving this treatment in primary care 6 months later. These findings therefore clearly highlight the need for an integrated approach involving hospital specialists, primary-care physicians and the patient, to overcome the wide treatment gap in lowering even 'normal' cholesterol levels in high-risk patients in line with evidence-based medicine.