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REPLY
Risk Factors and Secondary Prevention in Women with Heart Disease
Michael G. Shlipak, MD, MPH;
Eric Vittinghoff, PhD; and
Stephen Hulley, MD, MPH
2 December 2003 | Volume 139 Issue 11 | Pages 954-955
IN RESPONSE:
We appreciate the concerns of Mr. Rathore and Dr. Krumholz and acknowledge that our study had certain limitations. One of these, as we noted, was the absence of the type of information on contraindications to each therapy that had been provided in the Cooperative Cardiovascular Project (CCP) (1). However, our study had the strength of evaluating stable outpatients with coronary heart disease (CHD) and recording medication use at 4-month intervals throughout a 4-year follow-up period. In contrast, the CCP evaluated outpatient therapy only at the time of hospital discharge for MI.
Rathore and Krumholz suggest that a substantial proportion of untreated women in our study could have had contraindications to the therapies. We disagree that this is a major flaw. The finding that only half of the women with CHD and low-density lipoprotein cholesterol levels greater than 3.4 mmol/L (>130 mg/dL) were taking lipid-lowering therapy clearly represents substantial undertreatment. Nor can we be satisfied with our observation that only one third of women in HERS with previous MI were taking ß-blockers. Rathore and Krumholz's assertion that half of elderly patients with MI have contraindications to ß-blockers is arguable. The contention is based on CCP criteria that categorize heart failure and diabetes as relative contraindications (1), but in fact ß-blockers are clearly indicated for heart failure and are beneficial in the setting of diabetes (2). We previously estimated that only 8% of elderly patients with MI had absolute contraindications to ß-blockers (3), on the basis of CCP data published by Krumholz and colleagues (4).
Our concern with undertreatment in patients with coronary disease is consistent with other reports (5) and is not intended to be alarmist or to blame providers. The goal is to encourage health care providers to pay more attention to the positive steps they can take for high-risk patients. We hope the press reports of our findings will foster doctor–patient communication and will encourage women with CHD to ask their providers about treatment with aspirin, ß-blockers, and lipid-lowering therapy if they are not already receiving these medications.
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Author and Article Information
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From Veterans Affairs Medical Center, San Francisco, CA 94121; and University of California, San Francisco, San Francisco, CA 94115.
1. Marciniak TA, Ellerbeck EF, Radford MJ, Kresowik TF, Gold JA, Krumholz HM, et al. Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project JAMA. 1998;279:1351-7. [PMID: 9582042].[Abstract/Free Full Text]
2. Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. UK Prospective Diabetes Study Group BMJ. 1998;317:713-20. [PMID: 9732338].[Abstract/Free Full Text]
3. Phillips KA, Shlipak MG, Coxson P, Heidenreich PA, Hunink MG, Goldman PA, et al. Health and economic benefits of increased ß-blocker use following myocardial infarction JAMA. 2000;284:2748-54. [PMID: 11105180].[Abstract/Free Full Text]
4. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of ß-blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project JAMA. 1998;280:623-9. [PMID: 9718054].[Abstract/Free Full Text]
5. McCormick D, Gurwitz JH, Lessard D, Yarzebski J, Gore JM, Goldberg RJ. Use of aspirin, ß-blockers, and lipid-lowering medications before recurrent acute myocardial infarction: missed opportunities for prevention? Arch Intern Med. 1999;159:561-7. [PMID: 10090112].[Abstract/Free Full Text]
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