Most Stable Angina Patients Not Taking First-line Meds

Only one-third of US patients diagnosed with angina are taking all three guideline-recommended first-line therapies, according to data from the National Health and Nutrition Examination Study (NHANES).

The findings are important given the recent ISCHEMIA trial, which found no differences in the primary endpoint of cardiovascular events for patients treated with best medical therapy as compared with an initial invasive approach. Rahul Aggarwal, MD (Beth Israel Deaconess Medical Center, Boston, MA), stressed that if the take home from ISCHEMIA is that an invasive strategy doesn’t improve prognosis over optimal medical therapy (OMT), the picture changes when patients aren’t actually on the drugs that will reduce their risk of events.

“We keep coming up with different interventions, whether that be medications or procedures, that have high patient benefit,” Aggarwal, lead investigator of the new report, told TCTMD. “But the question we sometimes don't look at is: are we actually delivering that benefit to the patients? If optimal medical therapy works, that's great, but there are so many more patients that we can help just by increasing the proportion of patients that are actually on therapy.”

Study coauthor Nicolas Chiu, MD (Beth Israel Deaconess Medical Center), characterized disappointing medication adherence as the “gap between what we know and what we do.”

“In ISCHEMIA, doing an invasive approach and optimal medical therapy, they weren't able to find a statistically significant difference, but that was in the confines of a very well-controlled randomized trial where they were closely monitoring everyone's adherence,” Chiu told TCTMD. “But the benefit we see from optimal medical therapy [in ISCHEMIA]—that only translates if, in practice, everyone is taking their medications optimally.”

And indeed, supplemental data published alongside the ISCHEMIA papers earlier this year indicate that use of beta-blockers and antianginals was suboptimal in the trial; analyses addressing ISCHEMIA outcomes in relation to medication adherence have been promised.

Unsurprising Results

Published online in the American Heart Journal, Aggarwal and colleagues’ analysis used individual patient-level data from five cycles of the NHANES survey to estimate the US population with angina as well as the uptake of beta-blockers, antiplatelets, and statins. Of nearly 5.5 million US adults aged 40 years or older with physician-diagnosed angina, only 61.7% were on beta-blockers, 66.8% were on statins, and 54.4% were on an antiplatelet drug. Just 32.6% were taking all three first-line medications.

ACE inhibitors and ARBs, which are only guideline-recommended for a subset of angina patients, were used in 54.3% of patients.

Commenting on the study for TCTMD, William Boden, MD (VA New England Healthcare System, Boston, MA), said he was “not surprised” by the numbers, which, although observational, largely echo a 2013 analysis combining the COURAGE, FREEDOM, and BARI 2D trials that demonstrated the underuse of secondary prevention medications in patients with coronary artery disease and diabetes.

“We'll have to wait and see whether ISCHEMIA moves the needle,” Boden said. “I’m a bit pessimistic to think that all of a sudden ISCHEMIA will be the epiphany that we've all been missing for the last decade and that suddenly people are going to be more vigilant about prescribing medical therapy, but I don’t know.” All clinical trial results, he added, tend to take some time to filter down to clinical practice.

Physicians, Boden said, tend to have a laundry list of reasons why patients don’t get OMT. “They tell me medical therapy is too hard, it takes too much time, it's too labor intensive, patients develop side effects, they don't like taking them—we find all these reasons to make excuses about why we shouldn't spend more time with our patients to make sure they understand why it's important to take their medications.”

I’m a bit pessimistic to think that all of a sudden ISCHEMIA will be the epiphany that we've all been missing for the last decade and that suddenly people are going to be more vigilant about prescribing medical therapy. William Boden

Taking that extra time is critical, Boden said, but it doesn’t need to fall to physicians: nurse practitioners, physician assistants, and even pharmacists all have the skills and tools to be able to help with patient education.

“The only way that we can really mitigate subsequent events is to prevent new plaque ruptures and that’s what medical therapy does, in aggregate, if you use these medications together,” Boden said. Low uptake of proven medications in this setting “is multifactorial,” he concluded. “There’s clearly some inertia on the part of doctors dismissive about the fact that it's labor intensive and takes too long, and I think there's also a knowledge gap or an awareness gap on the part of patients.”

Aggarwal pointed out that since medications are typically prescribed and titrated in the clinic, additional barriers like scheduling and transportation can also affect whether patients get their meds. The wider use of telehealth and other services that have evolved to connect patients and ease access to prescriptions during the COVID-19 pandemic have removed some of these burdens; these novel strategies may point to a way forward, postpandemic, for helping to improve patient compliance, he suggested.

Hospital avoidance during COVID-19 has already had a devastating impact on the number of urgent interventional procedures for acute coronary syndromes. But the “flip side” of that, said Boden, is “the patients who are more stable who maybe were scheduled to have an elective procedure [but] decided, look, I'm not going to go to the hospital, I don't want to run the risk. I’ll just stay home and take my medications and see how I feel.”

Physicians, in turn, may have responded by making sure that their patients are taking the right medications at the right dose, Boden continued. “I think COVID has inadvertently created an imperative to treat conservatively. And conservatively doesn't mean that you're not treating, it means that you're making sure patients are taking their medical therapy as prescribed.”

That also goes for patients who have already had PCI, in whom physicians tend to have a “blind spot” about making sure they, too, are getting secondary prevention mediations, he added. “It will be fascinating to observe a year or so from now, to go back in time and see whether the trajectory of events has declined post-COVID. It may. . . . Maybe that can point us in the direction of getting clarity on this issue.”