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> Major medications
Major Medications for Risk Factor Modification
Aspirin; Betablockers; Ace-Inhibitors/ATR-Antagonists; Thiazide-diuretics; Aldosterone-Antagonists; Statins

Large randomized controlled trials and systematic reviews of those trials have highlighted the effectiveness of certain groups of medications in significantly reducing cardiovascular morbidity and mortality. Important examples are Aspirin, Beta-blockers, ACE-inhibitors/ATR-antagonists, Thiazide-diuretics, Aldosterone-antagonists and Statins.
While every drug given to any patient must be carefully considered, it should be remembered that these drugs, when given under the appropriate indications, save lives.
As usual the important questions are: which drug for which patient and to what end? The table below offers concise answers together with selected references. Information regarding dosage, adverse reactions, contraindications and all relevant drug-prescription information should be obtained from the appropriate sources.

Drug Group

For Whom?

To What End?

Selected References

Aspirin

Patients with a total 5-year risk for coronary artery disease (CAD) >= 3%

Primary prevention of CAD.

1,2,18

Patients with established CAD

Secondary prevention of CVD

3,18

Beta-Blockers

Patients after a myocardial infarction

Improved total survival and Decreased risk for re-infarction

4,18

Patients with mild-moderate heart failure (NYHA II-III).

Reduction of cardiovascular morbidity and mortality.

5,18

Ace-Inhibitors/ATR-antagonists

Patients with CAD and decreased left ventricular function

Improved total survival
Decrease in hospitalizations

6, 7, 8, 9,10,18

Hypertensive diabetics

Improved survival

Patients with diabetes and CAD considered at high risk.

Improved survival.
Decreased risk for MI, stroke, nephropathy and retinopathy

Patients with diabetic nephropathy.

Reduction in progression to macroalbuminuria
Reduction in progression to end stage renal disease

Thiazide-Diuretics

Consider as first choice for most hypertensive patients including-hypertensive patients with co-morbidities such as Heart failure, Diabetes, High coronary Risk and Post- Stroke.

Prevention of major Cardiovascular events

11,12,13, 14

Aldosterone-Antagonists

Patients with Symptomatic Left- Ventriclar Dysfunction or End Stage Heart Disease.

Reduction of Morbidity and Mortality

15,16

Left- Ventriclar Dysfunction Post Myocardial Infarction

Reduction of Morbidity and Mortality

Statins See: Table below Primary and secondary prevention of CVD 17, 18

 

Risk category Ldl goal Ldl level at which to initiate therapeutic lifestyle changes (TLC) Ldl level at which to consider drug therapy

Comments
CHD or CHD risk equivalents (10-year risk >20%) <100 mg/dl
optional<70mg/dl		 100 mg/dl 100 mg/dl
<100mg/dl: consider drug options 		Statins – drug of choice for lowering cholesterol levels
2+ risk factors (10-year risk 10- 20%) <130 mg/dl
optional<100mg/dl		 ≥130 mg/dl ≥130 mg/dl
(100-129mg/dl: consider drug options)		 For calculating ten-year risk, see Heart Disease Risk
2+ risk factors (10-year risk<10%) <130 mg/dl ≥130 mg/dl >160mg/dl  
0-1 risk factor* <160 mg/dl ≥160 mg/dl 190 mg/dl
(160-189 mg/dl: Ldl-lowering drug optional) 		 

References

  1. U.S. Preventive Services Task Force (USPSTF) recommendation for aspirin for the primary prevention of cardiovascular events, 2002.

  2. Aspirin for the secondary prophylaxis of vascular disease in primary care. University of Newcastle upon Tyne. Centre for Health Services Research; University of York. Centre for Health Economics. Health Services Research; York: University of York, Centre for Health Economics, 1998: 1-47. DARE abstract 988725

  3. Freemantle N, Cleland J. Beta blockade after myocardial infarction: systematic review and meta- regression analysis. BMJ 1999; 318: 1730–1737.

  4. CIBIS-II Investigators and Committees. The cardiac insufficiency bisoprolol study II (CIBIS-II): A randomized trial. Lancet 1999; 353: 9-13.

  5. Garg R et al, Overview of randomized trails of angiotensin-converting enzyme inhibitors on mortality and morbidity in patients with heart failure, JAMA 1995, 273 (18), 1450

  6. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and 6 Treatment of High Blood Pressure. Bethesda (MD): U.S. Department of Health and Human services, Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute; May 2003.

  7. HOPE Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: result of HOPE study and MICRO-HOPE substudy. Lancet 2000 355: 253-259.

  8. ACE-inhibitors for renal disease and diabetes? Bandolier. July 2001; 89-2 http://www.jr2.ox.ac.uk/bandolier/band89/b89-2.html

  9. Dahlof B, Devereux RB, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): A randomised trial against atenolol. Lancet. 2002;359:995-1003. RA

  10. Cohn JN, Tognoni G. A randomized trial of the angiotensin-receptor blocker valsartan in chronic heart failure. N Engl J Med. 2001;345:1667-75. RA

  11. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA. 2002;288:2981-97.

  12. American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003;26(suppl 1):S80-S82. PR

  13. PROGRESS Collaborative Group. Randomised trial of a perindopril-based blood-pressure-lowering
    regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet. 2001;358:1033-41. RA

  14. Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihyperten-sive therapies used as first-line agents. A systematic review and meta-analysis. JAMA. 1997;277:739-45. M

  15. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341:709-17. RA

  16. Pitt B, Remme W, Zannad F, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309-21. RA

  17. Statins. Bandolier. Jan 1998 47-2. http://www.jr2.ox.ac.uk/bandolier/band47/b47-2.html

  18. Hippisley-Cox J and Coupland C. Effect of combinations of drugs on all cause mortality in patients with ischaemic heart disease: Nested case-control study. BMJ 2005 May 7; 330:1059-63.