Response to Letter Regarding Article, “Long-Term Adherence to Evidence-Based Secondary Prevention Therapies in Coronary Artery Disease”
We thank Drs Jezior and Sullenberger for their interest in our article1 and agree that our observations on consistent use of proven therapies are indeed sobering. Importantly, we examined long-term consistent use, not discharge use, of evidence-based therapies, and did so specifically in patients with coronary artery disease (CAD). Of these patients, 8914 (28%) had heart failure; >61% of those patients had a documented ejection fraction (EF) <40. With regard to angiotensin-converting enzyme inhibitor (ACEI) use in CAD populations, there are differences in and overlap between practice guidelines. The American College of Cardiology/American Heart Association ST-elevation myocardial infarction guidelines recommend (Class I) ACEI in all patients indefinitely,2 and the non–ST-elevation acute coronary syndrome guidelines recommend (Class I) discharge and long-term use of “ACEIs for patients with [congestive heart failure], [left ventricular] dysfunction (EF less than 0.40), hypertension, or diabetes” (p 60).3 The ACC/AHA chronic stable angina guidelines recommend (Class I) “ACE inhibitor in all patients with CAD who also have diabetes and/or LV systolic dysfunction,” and (Class IIa) “ACE inhibitor in patients with CAD or other vascular disease” (p 166).4 Given the characteristics of our population, we felt these guidelines were appropriate benchmarks, but acknowledge that consideration of multiple guidelines may influence one’s decision for an individual patient. Because most of our patients with CAD and heart failure had a documented EF <40, we do not believe the major message of our article would change by focusing on the group with an EF <40. That is, all secondary prevention medications, including ACEIs, are woefully underused and consistent long-term use is poor among patients with CAD, including those with clearly-defined left ventricular systolic dysfunction. Our group is currently preparing a manuscript that will directly address use of ACEIs relative to existing guidelines for populations defined specifically by reduced EF.
Sources of Funding
Dr Newby has received a research grant from BMS-Sanofi. Dr Allen LaPointe has received research grants from Pfizer and Merck and other research support from Reliant and Eli Lilly. Dr Kramer has received a research grant from Pfizer and PhRMA. Dr Califf has received research grants from GlaxoSmithKline, Merck, Novartis AG Group, Novartis Pharmaceutical, Pfizer, Sanofi-Aventis. and Schering Plough.
Dr Newby has served on a speakers bureau for BMS-Sanofi-Aventis. Dr Kramer received an honorarium from Icagen. Dr Califf has received honoraria from Merck, Novartis Pharmaceutical, Pfizer, Sanofi-Aventis, and Schering Plough. Drs DeLong and Muhlbaier and B.G. Hammill and A.Y. Chen report no conflicts.
Newby LK, LaPointe NM, Chen AY, Kramer JM, Hammill BG, DeLong ER, Muhlbaier LH, Califf RM. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation. 2006; 113: 203–212.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, Hochman JS, Krumholz HM, Kushner FG, Lamas GA, Mullany CJ, Ornato JP, Pearle DL, Sloan MA, Smith SC Jr. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction; A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of patients with acute myocardial infarction). 2004; 44: E1–E211.
Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, Jones RH, Kereiakes D, Kupersmith J, Levin TN, Pepine CJ, Schaeffer JW, Smith EE, Steward DE, Theroux P. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients with Unstable Angina). Available at: http://www.acc.org/clinical/guidelines/unstable/unstable.pdf. Accessed April 10, 2006.
Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, Ferguson TB Jr, Fihn SD, Fraker TD Jr, Gardin JM, O’Rourke RA, Pasternak RC, Williams SV; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation. 2003; 107: 149–158.