Statins mostly lack unpleasant
side effects, yet they're plagued by poor compliance.
We know why: they don't immediately make the patient
feel better, and many patients who take them never felt
sick in the first place. Some docs have suggested that
if patients understood their cardiovascular risk better
and how the meds help reduce that risk, they'd be more
likely to stick with their meds. This has been tried
a few times, but the ways in which physicians measure
cardiovascular risk can be baffling to patients.
A large Canadian collaboration
has now tried again, using an approach that measures
patients' cardiovascular age to drive the message home.
Their promising results are presented in the November
26 Archives of Internal Medicine.
COMPLIANCE
YO-YO
The study, called CHECK-UP (Cardiovascular Health Evaluation
to Improve Compliance and Knowledge Among Uninformed
Patients), assembled 230 primary care physicians across
Canada, and 2,687 patients whose health status ran the
whole gamut from low Framingham risk to symptomatic
cardiovascular disease. These were randomized into two
groups. The control group received standard lipid therapy
including statins. The other group got the same drugs,
but these patients were also regularly shown their cardiovascular
risk profile, and how it improved over time as they
took their medicine or made lifestyle changes. The researchers,
led by Dr Steven Grover of McGill University, hypothesized
that this would encourage patients to stay on their
statins.
They hypothesized correctly. There
was a statistically significant trend among these patients
towards bigger treatment effects. But the measured effect
was modest over the 12 months' follow-up. Patients in
the control group saw their LDL levels fall by an average
48.0 mg/dL, while those getting regular cardiovascular
risk assessments lost an average of 51.2 mg/dL.
The main reason this study may
have underestimated the potential benefits of showing
patients their risk assessments was the large number
of low-risk patients in the trial. These patients were
often reassured upon seeing their cardiovascular risk
profile, and left the physician's office less worried
than when they entered it. The result was apparently
decreased compliance.
In the real world, however, that's
less of a problem, because these aren't the patients
we most need to persuade to take statins. Unfortunately,
the most at-risk patients of all, those who already
had symptomatic disease, were also largely unmoved.
The authors were not much surprised by this finding,
since these patients already knew they were high-risk.
That leaves the three middle quintiles,
in which the treatment effect was concentrated. And
it grew stronger the higher the patient's apparent risk
was. But this is where the study gets really interesting
and breaks new ground.
CARDIOVASCULAR
AGE
The risk was primarily measured in asymptomatic patients
using standard Framingham equations. But Framingham
risk categories seemed to leave the patients cold, both
in the researchers' anecdotal experience and in the
final analysis. Even telling patients their remaining
life expectancy and how it was changing with their lipid
profile had little effect.
What really struck home with these
patients was a novel way of measuring cardiovascular
risk called cardiovascular age. This is the patient's
age minus the difference between his or her estimated
remaining life expectancy (adjusted for coronary and
stroke risk) and the average remaining life expectancy
of Canadians of the same age and sex. So if a patient
is 50 and has a life expectancy of 75 given their risk
factors, when the average Canadian 50-year-old will
live to 80, they are assigned a cardiovascular age of
55.
Not to put too fine a point on
it, all indications are that this approach scares patients
silly. Detailed analysis showed that the strongest predictor
of improved treatment efficacy, and presumably improved
compliance, was a large gap between patients' cardiovascular
age and their real age.
In a helpful editorial in the same
issue, two New Zealand cardiologists share their country's
experience with telling patients their risk. In essence,
a paper-based effort failed because it generated too
much work, but a computerized approach was widely taken
up. The Canadian researchers also used software to provide
patients with a simple one-page risk printout.
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