Volume 193 - Issue 2
Cardiovascular risk perception and evidence–practice gaps in Australian general practice
Authors: Emma L Heeley, Craig S Anderson, Anushka A Patel, Alan Cass, David P Peiris and John P Chalmers
Med J Aust 2010; 193 (2): 127-128. || doi: 10.5694/j.1326-5377.2010.tb03824.x
Published online: 19 July 2010
Published online: 19 July 2010
In reply: We thank Radford for his insightful comments, seasoned with spice from the frontline of primary care. Although guidelines are an accepted part of clinical practice, they are just recommendations and are not without their limitations. Treatments need to be individually tailored according to many factors. Our aim, therefore, was to provide a current snapshot of adherence to cardiovascular guidelines in primary care in Australia.1 It would be naive of us to think that there would be complete adherence to the guidelines in the “real world”. We wished to obtain an overall benchmark figure and, more importantly, identify treatment gaps or disparities in care across important patient subgroups defined by risk of cardiovascular event.
We recognise that digital blood pressure (BP) monitors are no better than mercury sphygmomanometers and require frequent (6-monthly) calibration. However, BP measurement technique is a far more important issue. The use of digital BP monitors in our study provided a standardised measurement machine, but we had no influence on their use or on BP measurement technique.
Radford makes a good point regarding the absence of direct randomised trial evidence for the benefit of more intensive BP lowering. The BP target of less than 140/90 mmHg in individuals who are at high risk of a cardiovascular event, such as those with diabetes or chronic renal failure, is a sensible extrapolation from consistent observational epidemiological data. There is, however, convincing evidence of the benefits of multifactorial cardiovascular risk intervention among individuals at high risk.2 We also believe that the available data from randomised trials3,4 provide support for the efficacy of lowering BP in the elderly, and are more robust than the observational data cited by Radford. Similarly, systematic analysis of randomised trials of statin therapy supports efficacy of treatment in older patients.5 Despite their limitations, we believe that current evidence-based recommendations regarding preventive therapies are appropriate guidelines for managing patients who are at risk of a cardiovascular event. As with any guidance for clinical decision making, the application of these recommendations needs to take into account individual patient characteristics and circumstances.
Finally, we believe that Servier’s support for this study demonstrates a successful academia–industry partnership. The academic partners had full control of the study design, analyses and publications.
References
- Heeley EL, Peiris DP, Patel AA, et al. Cardiovascular risk perception and evidence–practice gaps in Australian general practice (the AusHEART study). Med J Aust 2010; 192: 254-259. 0_CACDABII
- Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008; 358: 580-591. 0_i1092206
- Beckett NS, Peters R, Fletcher AE, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008; 358: 1887-1898. 0_i1092208
- Blood Pressure Lowering Treatment Trialists’ Collaboration; Turnbull F, Neal B, Ninomiya T, et al. Effects of different regimens to lower blood pressure on major cardiovascular events in older and younger adults: meta-analysis of randomised trials. BMJ 2008; 336: 1121-1123. 0_i1092210
- Baigent C, Keech A, Kearney PM, et al; Cholesterol Treatment Trialists’ Collaborators. Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins. Lancet 2005; 366: 1267-1278. 0_i1092214