Elderly CHD patients less likely to receive optimal secondary prevention
Sir,
the article by Brady et al focused on secondary prevention in
patients with coronary heart disease (CHD) in primary care(1). Since it
has been demonstrated that prescribing behaviour of general practitioners
is greatly influenced by the medication given at discharge after a
hospitalisation(2,3), we analysed data from the Italian Group of
Pharmacosurveillance in the Elderly (GIFA), which surveyed 32203 patients
admitted to about 40 clinical centers throughout Italy during two 2-month
periods between 1988 and 1998(4). Limiting the analysis to 1997 and 1998
surveys to allow a meaningful comparison, we found that nearly 20% of
patients (n=1775) had a discharge diagnosis of CHD. Mean age was 74±12
years, men represented 58% and were significantly younger than women (mean
age 71±12 vs. 79±9 years, respectively; p<_0.001. p="p"/> Relative to those in primary care, a higher proportion of
hospitalized patients appeared to attain optimal blood pressure control
(>160/90 mmHg in 5% of men and 9% of women) and cholesterol levels
(>5 nmol in 9% of both men and women). Instead, at discharge a lower
proportion of patients was taking either an aspirin (men=41%, women=29%),
a ß-blocker (10%, and 6%), or a statin (7%, and 4%).
Despite the different settings, the intrinsic heterogeneity of the
samples, and/or the cultural differences, we hypothesize that patient age
is a factor which deeply influences the way preventive measures are
undertaken in CHD patients. In fact, while one could attribute the worse
treatment figures for women observed by Brady to gender per se, we think
they might be due to the age difference (72 vs. 67 years). Data reported
in table support our hypothesis.
The lower prevalence of hypercholesterolemia and diabetes mellitus
among older patients likely reflect selective survival, rather than a
better clinical practice. Instead, these patients attained suboptimal BP
control in higher proportion and they received fewer medications. At a
logistic regression analysis, the likelihood of not receiving preventive
treatments was strongly associated with age (Table 2).
Likelihood of not receiving*
Aspirin ß-blockers ACE inhibitors Statins
OR (95% CI)† OR (95% CI) OR (95% CI) OR (95% CI)
Age (years)
<_70 _1.0="_1.0" _70-80="_70-80" _1.9="_1.9" _1.5-2.5="_1.5-2.5" _3.0="_3.0" _2.0-4.5="_2.0-4.5" _1.1="_1.1" _0.9-1.5="_0.9-1.5" _1.8-4.8="_1.8-4.8"/>80 2.4 (1.8-3.1) 12.0 (6.3-23.2) 1.8 (1.4-2.4) 13.0 (5.8-
29.3)
* adjusted for gender; † OR (95% CI) = Odds Ratio (95% Confidence
Interval)
A substantial body of evidence has been accumulated demonstrating the
efficacy of preventive measures both in younger and older CHD patients.
Although it is true that elderly people often suffer from multiple
diseases and that clinical judgement should always prevail when deciding
whether to treat or not to treat, it appears unwarranted not to carry out
preventive measures solely on the basis of age(5).
In conclusion, Brady et al. fail to identify age as an important
determinant of inadequate compliance to the implementation of preventive
measures in CHD patients. Optimal treatment seems still biased by an
unjustified prejudice toward aged persons, both in primary and secondary
care.
1. Brady AJB, Oliver MA, and Pittard JB. Secondary prevention in 24
431 patients with coronary heart disease: survey in primary care. BMJ
2001;322:1463
2. Khan M, Mukkamala A, Taylor DK, Espinosa A, Duff J. Use of lipid
drugs with acute myocardial infarction patients: an examination of
physician prescribing behaviors. J Cardiovasc Pharmacol Ther 1998;3:217-22
3. Sarasin FP, Maschiangelo ML, Schaller MD, Heliot C, Mischler S,
Gaspoz JM. Successful implementation of guidelines for encouraging the use
of beta blockers in patients after acute myocardial infarction. Am J Med
1999;106:499-505
4. Carbonin P, Pahor M, Bernabei R, Sgadari A for the Gruppo Italiano
di Farmacovigilanza nell'Anziano (G.I.F.A.). Is age an independent risk
factor of adverse drug reactions in hospitalized medical patients? J Am
Geriatr Soc 1991;39:1093-9
5. Sgadari A, Antonelli Incalzi R, Onder G, Pedone C, Gambassi G.
Lipid-lowering therapy in patients with coronary artery disease: sex or
age bias? Arch Intern Med 2000;160:2684
Antonio Sgadari, assistant professor,
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
L.go F. Vito, 1
00168 Rome, Italy
Rapid Response:
Elderly CHD patients less likely to receive optimal secondary prevention
Sir,
the article by Brady et al focused on secondary prevention in
patients with coronary heart disease (CHD) in primary care(1). Since it
has been demonstrated that prescribing behaviour of general practitioners
is greatly influenced by the medication given at discharge after a
hospitalisation(2,3), we analysed data from the Italian Group of
Pharmacosurveillance in the Elderly (GIFA), which surveyed 32203 patients
admitted to about 40 clinical centers throughout Italy during two 2-month
periods between 1988 and 1998(4). Limiting the analysis to 1997 and 1998
surveys to allow a meaningful comparison, we found that nearly 20% of
patients (n=1775) had a discharge diagnosis of CHD. Mean age was 74±12
years, men represented 58% and were significantly younger than women (mean
age 71±12 vs. 79±9 years, respectively; p<_0.001. p="p"/> Relative to those in primary care, a higher proportion of
hospitalized patients appeared to attain optimal blood pressure control
(>160/90 mmHg in 5% of men and 9% of women) and cholesterol levels
(>5 nmol in 9% of both men and women). Instead, at discharge a lower
proportion of patients was taking either an aspirin (men=41%, women=29%),
a ß-blocker (10%, and 6%), or a statin (7%, and 4%).
Despite the different settings, the intrinsic heterogeneity of the
samples, and/or the cultural differences, we hypothesize that patient age
is a factor which deeply influences the way preventive measures are
undertaken in CHD patients. In fact, while one could attribute the worse
treatment figures for women observed by Brady to gender per se, we think
they might be due to the age difference (72 vs. 67 years). Data reported
in table support our hypothesis.
The lower prevalence of hypercholesterolemia and diabetes mellitus
among older patients likely reflect selective survival, rather than a
better clinical practice. Instead, these patients attained suboptimal BP
control in higher proportion and they received fewer medications. At a
logistic regression analysis, the likelihood of not receiving preventive
treatments was strongly associated with age (Table 2).
A substantial body of evidence has been accumulated demonstrating the
efficacy of preventive measures both in younger and older CHD patients.
Although it is true that elderly people often suffer from multiple
diseases and that clinical judgement should always prevail when deciding
whether to treat or not to treat, it appears unwarranted not to carry out
preventive measures solely on the basis of age(5).
In conclusion, Brady et al. fail to identify age as an important
determinant of inadequate compliance to the implementation of preventive
measures in CHD patients. Optimal treatment seems still biased by an
unjustified prejudice toward aged persons, both in primary and secondary
care.
1. Brady AJB, Oliver MA, and Pittard JB. Secondary prevention in 24
431 patients with coronary heart disease: survey in primary care. BMJ
2001;322:1463
2. Khan M, Mukkamala A, Taylor DK, Espinosa A, Duff J. Use of lipid
drugs with acute myocardial infarction patients: an examination of
physician prescribing behaviors. J Cardiovasc Pharmacol Ther 1998;3:217-22
3. Sarasin FP, Maschiangelo ML, Schaller MD, Heliot C, Mischler S,
Gaspoz JM. Successful implementation of guidelines for encouraging the use
of beta blockers in patients after acute myocardial infarction. Am J Med
1999;106:499-505
4. Carbonin P, Pahor M, Bernabei R, Sgadari A for the Gruppo Italiano
di Farmacovigilanza nell'Anziano (G.I.F.A.). Is age an independent risk
factor of adverse drug reactions in hospitalized medical patients? J Am
Geriatr Soc 1991;39:1093-9
5. Sgadari A, Antonelli Incalzi R, Onder G, Pedone C, Gambassi G.
Lipid-lowering therapy in patients with coronary artery disease: sex or
age bias? Arch Intern Med 2000;160:2684
Antonio Sgadari, assistant professor,
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
L.go F. Vito, 1
00168 Rome, Italy
E-mail: antonio_sgadari@rm.unicatt.it
Giovanni Gambassi, associate professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Matteo Cesari, assistant professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Roberto Bernabei, associate professor
Centro di Medicina dell’Invecchiamento
Università Cattolica del Sacro Cuore
Rome, Italy
Competing interests: Age groups (years) <70(n=544) 70-80(n=593) >80(n=638) p*Risk factors Continued smoking 107 (20) 60 (10) 21 (3)