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Risk Factors and Secondary Prevention in Women with Heart Disease
- Michael G. Shlipak, MD, MPH;
- Eric Vittinghoff, PhD; and
- Stephen Hulley, MD, MPH
- From Veterans Affairs Medical Center, San Francisco, CA 94121; and University of California, San Francisco, San Francisco, CA 94115.
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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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 β-blockers. Rathore and Krumholz's assertion that half of elderly patients with MI have contraindications to β-blockers is arguable. The contention is based on CCP criteria that categorize heart failure and diabetes as relative contraindications (1), but in fact β-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 β-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, β-blockers, and lipid-lowering therapy if they are not already receiving these medications.
Michael G. Shlipak, MD, MPH
Veterans Affairs Medical Center; San Francisco, CA 94121
Eric Vittinghoff, PhD
Stephen Hulley, MD, MPH
University of California, San Francisco; San Francisco, CA 94115
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
- Copyright ©2004 by the American College of Physicians
