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Sir,The recent audit reported by Khonget al 1 demonstrated the under-use of HMG Co-A reductase inhibitors (statins) in patients following myocardial infarction. Essentially, it highlighted major deficiencies in care on the basis of recent evidence, thus identifying a therapeutic void in the management of these patients. These findings are not confined to the use of statins in the post-myocardial infarction setting and the epidemic of under-treatment of chronic heart failure with angiotensin-converting enzyme (ACE) inhibitors by both hospital-based and primary care physicians is worthy of consideration. In heart failure these drugs prolong life, improve symptoms, and reduce the frequency of hospital admission, with economic analyses suggesting that they are among the more cost-effective therapies in cardiovascular medicine. On the basis of a number of large randomised controlled trials it would seem, therefore, that the evidence for their use is overwhelming. However, they are grossly under-prescribed and the dose frequently not up-titrated. Recently, the appropriateness of the policy of increasing dosage to the therapeutic levels identified by the major clinical trials has been questioned, but ACE inhibitor therapy is not instituted at all in half the post-infarction patients who are deemed to require it.2 Community-based studies have shown even poorer rates of prescription3 and this is likely to reflect the difficulty in the recognition of heart failure on clinical grounds alone, as well as anxieties by physicians about adverse effects.
The authors suggest the implementation of departmental protocols to aid the appropriate use of statins on the coronary care unit and the consideration of the use of an ACE inhibitor should be an integral part of such protocols. The recognised deficiencies in the management of heart failure patients in the community have led to the introduction of programmes such as open access echocardiography4 and specialist heart failure clinics.5 Despite the provision of services such as these, improvement in patient care can only be achieved if the importance of new developments in therapy for common diseases is fully appreciated by physicians. The responsibility of keeping abreast of the current evidence regarding benefits of specific treatments must ultimately rest with the individual physician and in this respect continuing medical education has an important role to play in helping to ensure that patient care is based on such evidence.
This letter was shown to the authors of reference 1 who responded as follows:
Sir,We read with interest the comments of Dr Burgess and agree with his observations that the under-presciption of cost-effective therapy is not confined to the use of statins in post-infarct patients. Indeed, there is reason to believe that there is much potential for improvement in overall management of prevention of secondary coronary disease.1-1 The aim of our survey was to highlight the opportunity for increased use of lipid-lowering therapy in patients surviving an acute myocardial infarction. In this respect, we can only emphasise the findings that lipid-lowering therapy was used in only a small proportion of such patients admitted to our cardiac care unit (CCU) in 1996.
The delay and discrepancy between evidence and clinical practice is not a new finding but is clearly a complex isssue and not restricted to cardiovascular medicine. We did not investigate in depth the causes for this in our case. However, we suggested that incorporating the prescription of lipid-lowering therapy into the CCU protocol may help to address some of the shortfall in their use. This was based, in part, on the possibility that the encouraging observation that cholesterol levels were checked in 89% of subjects may have been attributable to the CCU protocol, and in part, on the favourable side-effect and safety profile of statins.1-2 In an attempt to complete the audit cycle, we have instituted changes to the CCU protocol whereby all patients with a cholesterol level greater than 4.5 mmol/l are started on a statin unless contra-indicated. Inital reports show that prescription rates for statins have improved and we aim to complete this study in the near future.