[Evidence-based pharmacological therapy of ischemic heart disease: with reference to the long-term prognosis]

Scientists verified facts. Physicians are also scientists, and should act in accordance with the verified facts. Considering the issue of therapeutic agents, medication should be based on drugs with proven efficacy for the treatment required, i.e., evidence-based medicine. Consideration of pharmacotherapy of ischemic heart disease in Japan from the aspect of improvement of long-term prognosis shows that calcium antagonists and nitrates, for which there is no evidence of improved long-term mortality, are commonly prescribed, whereas the use of beta-blockers, for which there is clear evidence of improvement, lags well behind Western countries. In the 1980s, when the efficacy of beta-blockers was proven in Western countries, calcium antagonists first appeared. Of course both patients and physicians tended to use these antagonists because of the excellent effects. Possibly the continuous marketing of new calcium antagonists has led to negative attitudes among physicians toward beta-blockers. In Japan close attention has never been paid to the FDA's advisory notice about nitrates issued in 1993. When a drug proves effective, then it becomes widely used. However, if a report demonstrates no efficacy of a drug, such evidence is not widely publicized in Japan even if the trial was internationally approved such as GISSI-3 (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico) and ISIS-4 (Fourth International Study of Infarct Survival). We should learn from the number of excellent megatrials conducted in Western countries. In treating patients, drugs with evidence of verified efficacy from those megatrials should be selected. The problems we have experienced with the short-acting calcium antagonists and Cardiac Arrhythmia Suppression Trial (CAST) studies must not be repeated.