The Treatment and Prevention of Coronary Heart Disease in Canada: Do Older Patients Receive Efficacious Therapies?

Abstract

Despite equal or enhanced efficacy, there is consistently less prescription of proven drugs among older cardiac patients. These care patterns may contribute to their enhanced risk. The causes underlying these practice patterns are complex, and their population impact may be undervalued by clinicians and managers. Improvement of these patterns is difficult, but ultimately it would be beneficial for this presently disadvantaged, readily identified, high risk patient population.

Use of cardiovascular drugs by home-dwelling coronary patients aged 75 years and older

“…ACE inhibitors are indicated in patients with systolic dysfunction, but according to the results of the HOPE study [15], patients with vascular disease also bene®t. The largest gap in the elderly is in the lipid medications [16], but also in aspirin and beta-blockers, re¯ecting the situation elsewhere [17,18,19]. For the time being, randomised trials of lipid lowering are lacking in individuals over 75 years of age.…”

Equity in access to exercise tolerance testing, coronary angiography, and coronary artery bypass grafting by age, sex and clinical indications

“…The Royal College of Physicians has stated: “in assessing the ability to benefit from treatment, chronological age is less important than other factors concerned with the biological ageing process and the presence of associated disease.”26 Efficacious treatments have their greatest impact when applied to patients at with the greatest risk 27. Although older patients are at higher risk of acute myocardial infarction and other cardiovascular events, they are less likely to receive potentially beneficial investigations.…”

From knowledge to practice in chronic cardiovascular disease: a long and winding road

“…Although they are universally present, the magnitude of care gaps varies within and across individual practices. For example, the use of ACE inhibitors or beta-blockers in HF varies across geographic areas, between specialists and nonspecialists, and between patient subgroups defined by age, gender, and co-existing illnesses (6,7,10).…”

“…For example, only 34% to 60% of eligible outpatients in Europe, Canada, and the U.S. receive angiotensinconverting enzyme (ACE) inhibitors and beta-blockers for HF, aspirin and beta-blockers for coronary artery disease, or warfarin for atrial fibrillation (2,6,7). Although less common, care gaps also include those situations in which therapies without proven benefit on hard outcomes such as death or hospitalization, or in some cases even potential harm (i.e., those in which the harms outweighed the benefits when evaluated in RCTs), are used.…”