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Just Accepted by Current Medical Research & Opinion Review The use of medications in the secondary prevention of coronary artery disease in the Asian region Jamshed Dalal, Lip-Ping Low, Dang Van Phuoc, Abdul Rashid Abdul Rahman, Eugenio Reyes, Arieska Ann Soenarta, Brian Tomlinson doi: 10.1185/03007995.2015.1010035 Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only Abstract Background: Cardiovascular diseases, of which coronary artery disease (CAD) is a significant contributor, are a leading cause of long-term morbidity and mortality worldwide In the years ahead, it is estimated that approximately half of the world’s cardiovascular burden will occur in the Asian region Currently there is a large gap in secondary prevention, with unrealised health gains resulting from underuse of evidence-based medications, including beta-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aspirin and other antiplatelet agents, and lipid-lowering drugs Despite the almost universal recommendation for these drugs in unstable CAD, their under-prescription is well documented for patients with acute heart failure, non-obstructive CAD, and for secondary prevention of CAD Objective: This article reviews the burden of CAD in Asian countries together with guidelines supporting evidence-based medication use from a secondary prevention perspective Methods: The MEDLINE database was searched from 2000 to 2013, inclusive, for country-specific data related to CAD and supplemented with unpublished registry data Results: In the post-discharge setting following hospital admission for acute coronary syndromes, medication prescription rates were low Beta-blocker prescription rates ranged from 49% in China to 99% in Singapore, ACE-inhibitor/ARB prescription rates ranged from 28% in China to 96% in Singapore, and lipid-lowering therapy rates ranged from 47% in China to 97% in Singapore Aspirin/antiplatelet drug prescription rates ranged from 86% in Indonesia to 99.5% in Singapore Recommendations are provided to improve patient outcomes and reduce the disease burden in Asia Conclusions: Despite recommendations issued in international and national guidelines, use of CAD medications in Asia remains suboptimal In the absence of clear contraindications, all patients with unstable CAD should receive these agents as secondary prevention This averts the need to target drug use according to risk, with high-risk features paradoxically associated with under-prescribing of such drugs © 2014 Informa UK Ltd This provisional PDF corresponds to the article as it appeared upon acceptance Fully formatted PDF and full text (HTML) versions will be made available soon DISCLAIMER: The ideas and opinions expressed in the journal’s Just Accepted articles not necessarily reflect those of Informa Healthcare (the Publisher), the Editors or the journal The Publisher does not assume any responsibility for any injury and/or damage to persons or property arising from or related to any use of the material contained in these articles The reader is advised to check the appropriate medical literature and the product information currently provided by the manufacturer of each drug to be administered to verify the dosages, the method and duration of administration, and contraindications It is the responsibility of the treating physician or other health care professional, relying on his or her independent experience and knowledge of the patient, to determine drug dosages and the best treatment for the patient Just Accepted articles have undergone full scientific review but none of the additional editorial preparation, such as copyediting, typesetting, and proofreading, as have articles published in the traditional manner There may, therefore, be errors in Just Accepted articles that will be corrected in the final print and final online version of the article Any use of the Just Accepted articles is subject to the express understanding that the papers have not yet gone through the full quality control process prior to publication REVIEW The use of medications in the secondary prevention of coronary artery disease in the Asian region Jamshed Dalal,1 Lip-Ping Low,2 Dang Van Phuoc,3 Abdul Rashid Abdul Rahman,4 Eugenio Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only Reyes,5 Arieska Ann Soenarta,6 Brian Tomlinson7 Centre for Cardiac Sciences, Kokilaben Dhirubhai Ambani Hospital, Mumbai, India; 2Low Cardiology Clinic, Mount Elizabeth Medical Centre, Singapore; 3Ho Chi Minh City University Medical Centre, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam; 4Cyberjaya University College of Medical Sciences, Cyberjaya, Malaysia; 5Department of Medicine, University of the Philippines – College of Medicine, Manila, The Philippines; 6National Cardiovascular Center, Harapan Kita Hospital, Jakarta, Indonesia; 7Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR Address for correspondence: Professor Brian Tomlinson, The Chinese University of Hong Kong, Division of Clinical Pharmacology, Department of Medicine and Therapeutics, 9/F., Clinical Sciences Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong, +852 2632 3139, btomlinson@cuhk.edu.hk [Short title: Use of medications in secondary prevention of CAD in Asia] Key words: Angiotensin converting enzyme inhibitors, Asian countries, aspirin, beta-blockers, coronary artery disease, secondary prevention, statins Abstract Background: Cardiovascular diseases, of which coronary artery disease (CAD) is a significant contributor, are a leading cause of long-term morbidity and mortality worldwide In the years ahead, it is estimated that approximately half of the world’s cardiovascular burden will occur in the Asian region Currently there is a large gap in secondary prevention, with unrealised health Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only gains resulting from underuse of evidence-based medications, including beta-blockers, angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aspirin and other antiplatelet agents, and lipid-lowering drugs Despite the almost universal recommendation for these drugs in unstable CAD, their under-prescription is well documented for patients with acute heart failure, non-obstructive CAD, and for secondary prevention of CAD Objective: This article reviews the burden of CAD in Asian countries together with guidelines supporting evidence-based medication use from a secondary prevention perspective Methods: The MEDLINE database was searched from 2000 to 2013, inclusive, for countryspecific data related to CAD and supplemented with unpublished registry data Results: In the post-discharge setting following hospital admission for acute coronary syndromes, medication prescription rates were low Beta-blocker prescription rates ranged from 49% in China to 99% in Singapore, ACE-inhibitor/ARB prescription rates ranged from 28% in China to 96% in Singapore, and lipid-lowering therapy rates ranged from 47% in China to 97% in Singapore Aspirin/antiplatelet drug prescription rates ranged from 86% in Indonesia to 99.5% in Singapore Recommendations are provided to improve patient outcomes and reduce the disease burden in Asia Conclusions: Despite recommendations issued in international and national guidelines, use of CAD medications in Asia remains suboptimal In the absence of clear contraindications, all patients with unstable CAD should receive these agents as secondary prevention This averts the need to target drug use according to risk, with high-risk features paradoxically associated with Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only under-prescribing of such drugs Introduction Coronary artery disease (CAD) is a leading cause of long-term morbidity and mortality worldwide.1 According to the World Health Organization (WHO) Global Burden of Disease estimates, heart disease is a leading contributor to years living with disability in elderly people in low- and middle-income countries.2 Of the 57 million deaths worldwide in 2008, an estimated Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only 17.3 million were due to cardiovascular disease (CVD), with more than 80% of cardiovascular deaths occurring in low- and middle-income countries CVD is responsible for 151 million disability-adjusted life years, 62 million of which are due to CAD and 46 million due to cerebrovascular disease.2 Of particular concern, cardiovascular morbidity and mortality are predicted to increase substantially by 2030,3 with an estimated half of the world’s cardiovascular burden expected to occur in the Asian-Pacific region.4 Monitoring and management of cardiovascular risks as well as implementation of appropriate strategies to tackle the increase in CVD morbidity and mortality are essential.5,6 Based on the Framingham experience, the principal personal atherogenic risk attributes that independently predict CAD are blood lipids, blood pressure, glucose tolerance and fibrinogen.7 In addition, lifestyle factors including obesity, smoking, and diet and exercise habit can affect the level of atherogenic risk Findings of the global INTERHEART and INTERSTROKE studies suggest that approaches to CVD prevention, as well as control of cardiovascular risk factors, such as hypertension, abnormal lipid levels, tobacco use, obesity, diabetes mellitus, diets with low intake of fruits and vegetables, physical inactivity, excessive alcohol intake, and psychosocial factors, may be based on similar principles worldwide and have the potential to prevent most premature cases of myocardial infarction (MI) and stroke.8,9 The Reduction of Atherothrombosis for Continued Health (REACH) registry, which involved a total of 67,888 patients in 44 countries, confirmed that classic cardiovascular risk factors are consistent and common throughout the world.10 However, risk factors are largely undertreated and undercontrolled in many regions The Prospective Urban Rural Epidemiological (PURE) study further showed that there is a large gap in secondary prevention worldwide, highlighting the extremely Curr Med Res Opin Downloaded from informahealthcare.com by Mcgill University on 02/09/15 For personal use only low rates of effective therapy usage in low- and middle-income countries.11 This evidence emphasises the need for systematic efforts to identify reasons for underuse of drugs, and implement strategies for the long-term use of effective and inexpensive drugs for the prevention of CVD All patients with CAD require ongoing management, which includes medication, control of risk factors and lifestyle modification Acute coronary syndrome (ACS), which occurs in patients with unstable CAD and presents as unstable angina (UA), ST-elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (non-STEMI), typically requires aggressive medical management particularly in high-risk patients In this regard, most current treatment guidelines recommend the use of beta-adrenergic (ß)-blockers, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), aspirin and other antiplatelet agents, and lipid-lowering drugs as appropriate agents for the treatment and secondary prevention of CAD.12-15 However, despite the almost universal recommendation for these drug classes in the long term management of patients presenting with unstable CAD, their under-prescription has been well documented in patients with acute myocardial infarction (MI),16 acute heart failure,17,18 non-obstructive CAD (