Volume 180 - Issue 4
Prevention of cardiovascular disease: an evidence-based clinical aid
Authors: Gregory R Fulcher, John V Amerena and Greg W Conner
Med J Aust 2004; 180 (4): 197-198. || doi: 10.5694/j.1326-5377.2004.tb05874.x
Published online: 16 February 2004
Published online: 16 February 2004
Gregory R Fulcher,* John V Amerena,† Greg W Conner‡
* Director, Department of Diabetes, Endocrinology and Metabolic Medicine, Level 3, Main Block, Royal North Shore Hospital, St Leonards, NSW 2065; † Cardiologist, Department of Clinical and BioMedical Sciences, University of Melbourne, Melbourne, VIC; ‡ Vascular Physician, Cardiovascular Diagnostic Services, Sydney, NSW. gfulcherATmed.usyd.edu.au
In reply: We thank Cradick for his critical review of our publication.1 His interesting points illustrate some of the reasons we were keen to publish this work.
Firstly, the average practitioner is confused about which guidelines (both national and international) to follow. Cradick refers to the JNC 7 report and WHO/ISH guidelines (the committee is familiar with these), but which to follow? The committee decided a priori that Australian national guidelines, if they existed, would be referenced in preference to overseas ones. We mentioned that current Australian hypertension guidelines should be revised, and that clinical practice was probably at odds with these recommendations.
Secondly, guidelines quickly become dated. Cradick cites the recommendation of Hayden et al that aspirin should be introduced if the annual risk of a cardiovascular event is > 0.6%.2 The latest Australian guidelines3 recommending a > 1% annual risk as the treatment threshold were published just after we received Cradick’s letter. The Hayden article is thus (for some patients) at odds with current local recommendations. Consistent with our approach, we will include the Australian recommendations in the first update of our document (July 2004).
Cradick’s comments imply bias in the presentation of the data; yet he fails to substantiate this. Neither the clinical trials quoted (nearly all of which are funded by the pharmaceutical industry) nor the conclusions or inferences drawn have been challenged. He refers to the “heavy” emphasis on the use of ACE inhibitors and statins, implying that this is inappropriate. We would argue that, given the strength of the evidence, this emphasis is appropriate, and reflects current specialist practice in tertiary centres. Careful reading of the National Prescribing Service publications will show that “heavy” reference is made to the 4S,4 LIPID,5 CARE,6 and WOSCOPS7 studies (for example, NPS News 20 February 20028), as well as to the prescribing information for Lipitor (Pfizer), Pravachol (Bristol-Myers Squibb) and Zocor (Merck Sharp & Dohme). We must caution against “throwing the baby out with the bathwater”. The HPS, CARE, LIPID, WOSCOPS, HOPE, PROGRESS, 4S, CURE, and CREDO studies represent substantial and widely acclaimed clinical trials that have had a positive impact on clinical care. They have all been funded by the pharmaceutical industry.
Finally, about 130 GPs in clinical practice had some input in compiling and formatting this document. The document was tested before publication in over 30 000 patients, and was peer reviewed by several clinicians. It is a pity that Cradick was not a participant in any of these processes.
References
- Fulcher GR, Conner GW, Amerena JV, et al. Prevention of cardiovascular disease: an evidence-based clinical aid [Focus document]. Med J Aust 2003; 179 (21 July): 1-16. <eMJA full text>
- Hayden M, Pignone M, Phillips C, Mulrow C. Aspirin for the primary prevention of cardiovascular events: a summary of the evidence for the US Preventive Services Task Force. Ann Intern Med 2002; 136: 161-172. CBBFCEFA
- Hung J, for the Medical Issues Committee of the National Heart Foundation of Australia. Aspirin for cardiovascular disease prevention [position statement]. Med J Aust 2003; 179: 147-152. <eMJA full text>
- Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: 1383-1389. CBBIEJFI
- Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. The Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998; 339: 1349-1357. i1082914
- Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. Cholesterol And Recurrent Events trial investigators. N Engl J Med 1996; 335: 1001-1009. i1082916
- Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholesterolemia. West of Scotland Coronary Prevention Study Group. N Engl J Med 1995; 333:1301-1307. i1082918
- National Prescribing Service. News 20 February 2002. Prescribing pointers: lipid-modifying therapy. Available at: www.nps.org.au/site.php?content=/html/news.php&news=/resources/NPS_News/news20#pp (accessed Jan 2004).