Drugs for coronary heart disease
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Drugs for Coronary Heart Disease
Combination Therapy and Adherence
Importance of Combination Therapy
Combination therapy, involving aspirin, cholesterol-lowering drugs, and blood pressure-lowering drugs, significantly reduces the risk of coronary heart disease (CHD). However, the full preventive effect is only realized if treatment continues indefinitely.
Adherence Challenges
Adherence to these preventive treatments is generally poor. A meta-analysis of 376,162 patients found that the overall adherence rate was 57% after a median of 24 months. Adherence was notably higher in secondary prevention (66%) compared to primary prevention (50%). This suggests that patients who have already experienced a myocardial infarction are more likely to stick to their medication regimen than those who have not.
Drug Interactions in Coronary Heart Disease
Common Drug Interactions
Patients with CHD often receive multiple drugs, which can lead to significant drug interactions. For instance, combining aspirin with clopidogrel results in a moderate synergistic interaction, while combining antiplatelet agents with anticoagulants significantly increases the risk of bleeding. Additionally, the combination of nifedipine and atorvastatin can lead to a synergistic pharmacodynamic interaction.
Lipid-Lowering Drugs for Primary Prevention
Efficacy of Lipid-Lowering Drugs
Lipid-lowering drugs, particularly statins, are effective in reducing the odds of coronary heart disease events by 30% in primary prevention. However, these drugs do not significantly reduce all-cause mortality. This highlights the importance of lipid management in preventing CHD events, even though it may not impact overall mortality rates.
Secondary Prevention in Different Economic Contexts
Global Disparities in Drug Use
The use of secondary prevention drugs varies significantly across different economic contexts. In high-income countries, the use of antiplatelet drugs, beta-blockers, ACE inhibitors or ARBs, and statins is relatively high. However, in low-income countries, the usage rates of these drugs are substantially lower. For example, only 3.3% of patients in low-income countries use statins compared to 66.5% in high-income countries. This disparity underscores the need for systematic approaches to improve the long-term use of effective drugs, especially in low-income and rural areas.
Oral Anticoagulants in Coronary Heart Disease
New Developments in Anticoagulants
Vitamin K antagonists (VKAs) have been traditionally used for long-term treatment of CHD but are cumbersome to administer. The introduction of non-VKA oral anticoagulants (NOACs) like dabigatran, apixaban, and rivaroxaban offers a more manageable alternative. These NOACs can be administered in fixed doses without routine coagulation monitoring. However, their use is complicated by the increased risk of major bleeding and the uncertainty of their safety in combination with newer antiplatelet agents.
Medication Use in China
Adherence and Challenges
In China, the use of evidence-based medications for acute coronary syndromes is high at the time of hospital discharge but decreases significantly during follow-up. Less than half of the patients are discharged on a 4-drug combination therapy, and this proportion drops further after one year. Factors such as medical insurance, dyslipidemia, hypertension, and invasive therapies influence medication adherence.
Conclusion
Effective management of coronary heart disease involves a combination of various drug therapies, including antiplatelet agents, lipid-lowering drugs, and anticoagulants. Adherence to these medications is crucial but remains a significant challenge. Drug interactions and economic disparities further complicate the treatment landscape. Systematic approaches and improved adherence strategies are essential to optimize the use of these life-saving medications.
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