Treatment with life-saving drugs increases but still suboptimal in ischemic heart disease

"Ischaemic heart disease (IHD) remains the major killer across the globe and particularly in Europe," said principal investigator Professor Michel Komajda, professor of cardiology in the Department of Cardiology at University Pierre and Marie Curie and Pitié-Salpêtrière Hospital in Paris, France. "Although there have been substantial improvements in the management of these patients, IHD remains the most common condition in cardiology and is associated with very poor outcomes."

European data on patients with CICD and their management is lacking. The Euro Heart Survey published in 2005 was limited to patients with stable angina.3 In addition, the diagnosis and treatment landscape has changed in the past ten years with new stress imaging modalities for diagnosis, more efficient revascularisation, and an ageing population.

The EORP4 CICD-Pilot was an international prospective observational longitudinal registry, conducted in 100 centres from ten countries across Europe with three year follow-up. From April 2013 to December 2014, the study enrolled 2 420 consecutive patients with a broad spectrum of IHD including non-ST-elevation myocardial infarction (NSTEMI), stable angina, peripheral artery disease (PAD) and patients undergoing elective percutaneous coronary intervention (PCI). Data was collected on clinical characteristics, investigations and medications.

The investigators found an increased rate of prescriptions of life-saving medications compared to the Euro Heart Survey. At discharge from hospital, 93% of patients received a statin (up from 48%), 65% received an angiotensin converting enzyme inhibitor (ACE I) (up from 40%), and 80% received a beta-blocker (up from 67%).

"The increase in medications is a good sign," said Professor Komajda. "However, the proportion of patients who are taking all recommended medications at the same time remains suboptimal at 71% (ACE I/angiotensin receptor blocker (ARB), statin and aspirin) so there is room for improvement."

The proportion of patients receiving diagnostic and prognostic procedures was well below that recommended by ESC guidelines.5 In particular the assessment of cardiac function, which is recommended for all patients with CICD, was performed in just 70% of cases. Only 21% of patients who should have had an ischaemic test in the year preceding inclusion in the registry actually had one.

The use of modern imaging modalities, including cardiac computed tomography, myocardial scintigraphy and cardiac magnetic resonance, for assessment of myocardial ischaemia was very low, at less than 5% overall, and most stress test procedures used the classical exercise test. Professor Komajda said: "We were surprised to find such a low use of the newer imaging techniques. This may be because more than 40% of patients were from Eastern Europe where these tests may not be affordable."

Compared to the Euro Heart Survey, patients were older and more frequently had diabetes (29 vs 18%), dyslipidemia (74 vs 58%), hypertension (83 vs 62%), previous cerebrovascular disease (16 vs 5%) and malignancy (7% vs 2%). Within the CICD-Pilot Registry cohort, PAD patients were significantly older, had more comorbidities and were less treated with life-saving drugs.

"These results show that patients with CICD are more complex and have more comorbidities than ten years ago," said Professor Komajda. "And in addition, patients affected by atherosclerosis have different clinical presentations. Our finding that patients with PAD receive fewer recommended medications could be because they are not referred to cardiac departments."

He concluded: "We are launching the long-term phase of the CICD registry at ESC Congress in London. The target is to include 15 000 patients from as many European countries as possible. The survey will assess outcome measures and geographic variations. The data will ultimately be used to improve the diagnosis and treatment of patients with ischaemic heart disease."