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Primary prevention drug therapy: can it meet patients' requirements for reduced risk?
Hilary A Llewellyn-Thomas1, J Michael Paterson, Judy A Carter
1Center for the Evaluative Clinical Sciences, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire 03755-3863, USA.
Insights
Many patients require more risk reduction for cardiovascular disease prevention than medications like cholesterol-lowering or antihypertensive drugs can offer. Decision aids may help clarify patient preferences for accepting or refusing primary prevention medication.
Area of Science:
- Cardiology
- Preventive Medicine
- Health Decision Science
Background:
- Cardiovascular disease (CVD) prevention often involves medication.
- Patient risk perception and medication acceptance vary significantly.
- Understanding individual risk reduction needs is crucial for effective primary prevention.
Purpose of the Study:
- To identify primary prevention patients whose required risk reduction (ReqRR) exceeds achievable risk reduction (ARR) from cholesterol-lowering or antihypertensive medications.
- To explore the role of decision aids in clarifying patient preferences for CVD prevention medication.
Main Methods:
- Individualized 10-year CVD risk estimates were calculated for hypercholesterolemic (HC) and hypertensive (HT) patients.
- Patients' ReqRR was determined through trade-off tasks.
- ARR was estimated based on medication-induced changes in cholesterol and blood pressure.
- The ratio of ReqRR to ARR was analyzed.
Main Results:
- A significant proportion of patients (18-19%) would refuse medication regardless of risk reduction.
- Among remaining patients, 28% of HC and 37% of HT subjects were "over-requirers" (ReqRR/ARR ratio ≥ 1.5).
- This suggests a notable gap between perceived and achievable risk reduction for some individuals.
Conclusions:
- A substantial number of patients may have risk reduction needs unmet by current pharmacological primary prevention strategies.
- Decision aids could be valuable tools for helping patients navigate complex choices regarding CVD medication acceptance.
- Personalized risk-benefit communication is essential in primary CVD prevention.
Abstract:
The objective was to identify, in primary prevention, patients whose "required risk reduction" (ReqRR) is greater than the "achievable risk reduction" (ARR) that cholesterol-lowering or antihypertensive medication could provide. Individualized estimates of 10-year coronary heart disease or stroke risk were derived for 66 hypercholesterolemic (HC) and 64 hypertensive (HT) patients without symptomatic cardiovascular disease. These estimates were used in trade-off tasks identifying each individual's ReqRR. Then individual ARRs were estimated (in HC patients by assuming total cholesterol/high density lipoprotein ratio reductions to 5.0; in HT patients by assuming systolic blood pressure reductions to 120 mmHg). 12 (18%) HC and 12 (19%) HT subjects would refuse medication regardless of the risk reduction offered. Of the remaining patients, 15/54 (28%; 95% C.I.:16-40%) HC and 19/52 (37%; 95% C.I: 24-51%) HT subjects were "over-requirers," in that their ReqRR/ARR ratio was 1.5. There maybe a notable proportion of patients whose ReqRR is considerably greater than what is achievable, implying that decision aids may help individuals clarify preferences about accepting/refusing medication for the primary prevention of cardiovascular disease.