[Undertreatment in secondary prevention of patients with coronary heart disease after revascularization]

Coronary artery disease is still the no. 1 killer in the developed countries and must thus be detected and treated at an earlier stage. If coronary artery disease is advanced, patients have to be examined regarding the need for revascularization. For secondary prevention, of course, an optimal change of life style and optimal medical treatment of risk factors is mandatory. Independent of the optimal risk factor modification, all of these patients (according to the rules of evidence-based medicine) should take ASA, statins, beta blockers and ACE-inhibitors, if no contraindications or intolerance are present. Therefore, the problem in secondary prevention is not how to identify these patients, but rather how to fulfill their needs. In our own survey in patients with known coronary artery disease referred for PTCA (including patients with post myocardial infarction previous PTCA or bypass surgery), only 89% were on ASA (or clopidogrel), 51% on lipid lowering drugs (46% on statins), 65% on beta blockers, and only 43% had an ACE-inhibitor (MUNICH data in Figures 1 to 4). The analysis of published literature is also depicted in Figures 1 to 4. Until 1996, patients with known coronary artery disease took ASA in only 26% of the cases but later on it was 77 to 100% (Figure 1). Lipid lowering drugs (especially statins) are prescribed in only 13 to 77% (Figure 2), beta blockers in only 30 to 80% (Figure 3) and ACE-inhibitors in only 10 to 72% (Figure 4). In 2 major studies, a decrease in the rate of intake of these drugs during the follow-up years has been documented. The "ideal tablet" for secondary prevention contains ASA (100 mg), a statin (e.g. for most statins 40 to 80 mg), a beta blocker (e.g. metoprolol 100 mg or bisoprolol 10 mg) and an ACE-inhibitor (e.g. ramipril 10 mg). So this ideal "SPM" ("secondary prevention mix") tablet contains 160 to 300 mg of drugs. In conclusion, the analysis of published data for Europe and the USA shows that--in contrast to the statements of politicians and health care insurance companies--we are not overtreating but rather undertreating our patients regarding medications for secondary prevention.