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Physicians Slower To Incorporate Newer Heart Drug Treatments

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Duke Health News 919-660-1306

DALLAS -- An analysis of the treatment received by more than
100,000 heart patients has shown that physicians' prescription
practices for drugs proven effective for treating heart disease
has shown steady improvement over the past three years,
cardiologists at the Duke Clinical Research Institute (DCRI)
have concluded. However, they emphasized there is much room for
improvement, especially in the prescription of newer heart
drugs.

Use of newer medications has lagged behind that of older and
more established medications, they concluded. Also, lagging has
been physicians' practice of giving advice to patients upon
discharge from the hospital for such behavioral modifications
such as smoking cessation and diet control, said the
researchers.

The overall adherence to recommended medications rose from
71 percent at the beginning of the analysis in 2002 to 81.5
percent by the end of 2004, found the researchers. The use of
the older drug aspirin, for example, was consistently
prescribed to more than 96 percent of heart patients, while
newer drugs such as clopidogrel or glycoprotein IIb/IIIa
inhibitors were consistently prescribed less than 75 percent of
the time.

The researchers said that a usage rate of 95 percent or
higher for the new drugs would represent a successful adherence
to the guidelines.

"The good news is that we have made substantial improvements
in making sure that heart patients are receiving proven
medications," said Duke cardiologist Rajendra Mehta, M.D., who
presented the results of the analysis Nov. 14, 2005, at the
annual scientific sessions of the American Heart Association
(AHA) in Dallas.

"The trends in treatment practices are very encouraging,"
Mehta continued. "However, there is still much work to be done,
especially in improving the usage rates of some of the newer
medications. It appears that physicians have been slow to
incorporate the latest recommendations into their routine
practice."

The researchers analyzed how 113,595 patients were treated
at 434 U.S. hospitals as a part of a national effort to improve
the outcomes of patients with heart disease. They monitored the
use of specific drugs and physician recommendations – both
while in the hospital and at discharge -- that have been
established as national guidelines by the American College of
Cardiology (ACC) and the AHA.

For the analysis, Mehta drew on the database of a national
quality improvement initiative known as CRUSADE (Can Rapid Risk
Stratification of Unstable Angina Patients Suppress Adverse
Outcomes with Early Implementation of the ACC and AHA
Guidelines). CRUSADE maintains a national registry of data
collected from more than 400 hospitals nationwide and then
reports back to each hospital every three months on their
adherence to the guidelines.

The guidelines serve as a national model for optimal care of
patients who arrive at the hospital with symptoms of a possible
heart attack, such as chest pain (unstable angina), irregular
readings on an electrocardiograph or elevated chemical markers
of cell death.

The guidelines -- adopted after large-scale clinical trials
demonstrated the effectiveness of specific therapies in saving
lives -- focus on giving suspected heart attack patients
anti-platelet medications, heparin, glycoprotein IIb/IIIa
inhibitors (clot inhibitors) or beta-blockers within the first
24 hours of admission. The guidelines also call for prescribing
such drugs as aspirin, beta-blockers, ACE inhibitors or statins
after discharge, as well as recommendations for cardiac
rehabilitation, smoking cessation and dietary modification.

"We found that most of the hospitals participating in
CRUSADE have demonstrated substantial improvements in their
care of heart patients," said Duke cardiologist E. Magnus
Ohman, M.D., who also serves as CRUSADE executive chairman. "We
hope that these promising results will motivate more hospitals
to participate in quality improvement programs like CRUSADE or
develop their own programs that adhere to the ACC/AHA
guidelines."

Some of the specific trends from 2002 to 2004 follow:
-- Beta Blockers – In hospital usage improved from 76 percent
to 88 percent; outpatient usage improved from 81 percent to 89
percent
-- Aspirin – In-hospital rates improved from 92 percent to 97
percent; outpatient usage rose from 93 percent to 96
percent.
-- Clopidogrel (a newer agent that prevents platelets from
clumping) – In-hospital rates rose from 36 percent to 54
percent, while outpatient usage rose from 50 percent to 72
percent.
-- Glycoprotein IIb/IIIa inhibitors (a newer clot inhibitor
used only in hospital) improved from 33 percent to 47
percent.
-- Dietary modification – Improved from 66 percent to 83
percent.
-- Smoking cessation – Improved from 59 percent to 85
percent.
-- Cardiac rehabilitation improved from 37 percent to 65
percent.

DCRI researchers reported at last year's AHA meeting that
adherence to the guidelines measured by CRUSADE is definitely
linked to an improvement in outcomes. They reported that over
time, mortality risks rose by 3.1 percent at hospitals whose
adherence declined, while the mortality risks declined by 37
percent over the same time period among hospitals whose care
patterns were most improved.

CRUSADE is coordinated by the DCRI. It is funded by
Schering-Plough Corp, Kenilworth, N.J., with addition funding
from the Bristol-Meyers Squibb/Sanofi Pharmaceuticals
Partnership, NY, and Millennium Pharmaceuticals, Cambridge,
Mass. Mehta and Ohman have no financial interests in any of the
sponsors.

Note to editors: The researchers involved in CRUSADE can
only discuss data in the aggregate, and not about specific
hospitals.

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