SISANews

Ridurre o interrompere la terapia di prevenzione cardiovascolare in pazienti con un basso rischio di malattia cardiovascolare a 10 anni è sicuro nel breve termine

L'uso di farmaci cardiovascolari per la prevenzione primaria delle malattie cardiovascolari è potenzialmente inappropriato quando i potenziali rischi superano i potenziali benefici.
In questo studio pragmatico di non inferiorità, controllato e randomizzato, sono stati reclutati 1067 pazienti di età compresa tra i 40 e i 70 anni che, nonostante assenza di storia di malattie cardiovascolari e basso rischio di svilupparle (mediamente del 5% a 10 anni), stavano usando farmaci antipertensivi e/o ipolipemizzanti. A questi soggetti è stato proposto un protocollo che prevedeva la riduzione o l’interruzione della prescrizione di farmaci cardiovascolari.
Dopo 2 anni, il rischio cardiovascolare stimato risultava aumentato di 2,0 punti percentuali nel gruppo di intervento rispetto a 1,9 punti percentuali nel gruppo di cura standard, con evidenza significativa di non inferiorità. Per quanto riguarda gli esiti secondari, nel il gruppo di intervento la pressione arteriosa sistolica era più alta di 6 mmHg, la pressione diastolica era più alta di 4 mmHg e il colesterolo totale e i livelli di colesterolo LDL erano entrambi di 7 mg/dL più alti.
Ciò suggerisce che un tentativo di deprescrivere la terapia cardiovascolare preventiva in pazienti a basso rischio CVD è sicuro nel breve termine, a patto che i livelli di pressione e di colesterolo siano monitorati dopo l'interruzione.

Deprescribing preventive cardiovascular medication in patients with predicted low cardiovascular disease risk in general practice - the ECSTATIC study: a cluster randomised non-inferiority trial

Luymes CH, Poortvliet RKE, van Geloven N, de Waal MWM, Drewes YM, Blom JW, Smidt N, Assendelft WJJ, van den Hout WB, de Ruijter W, Numans ME

BMC Med 2018;16:5

BACKGROUND: The use of cardiovascular medication for the primary prevention of cardiovascular disease (CVD) is potentially inappropriate when potential risks outweigh the potential benefits. It is unknown whether deprescribing preventive cardiovascular medication in patients without a strict indication for such medication is safe and cost-effective in general practice.
METHODS: In this pragmatic cluster randomised controlled non-inferiority trial, we recruited 46 general practices in the Netherlands. Patients aged 40-70 years who were using antihypertensive and/or lipid-lowering drugs without CVD and with low risk of future CVD were followed for 2 years. The intervention was an attempt to deprescribe preventive cardiovascular medication. The primary outcome was the difference in the increase in predicted (10-year) CVD risk in the per-protocol (PP) population with a non-inferiority margin of 2.5 percentage points. An economic evaluation was performed in the intention-to-treat (ITT) population. We used multilevel (generalised) linear regression with multiple imputation of missing data.
RESULTS: Of 1067 participants recruited between 7 November 2012 and 18 February 2014, 72% were female. Overall, their mean age was 55 years and their mean predicted CVD risk at baseline was 5%. Of 492 participants in the ITT intervention group, 319 (65%) quit the medication (PP intervention group); 135 (27%) of those participants were still not taking medication after 2 years. The predicted CVD risk increased by 2.0 percentage points in the PP intervention group compared to 1.9 percentage points in the usual care group. The difference of 0.1 (95% CI -0.3 to 0.6) fell within the non-inferiority margin. After 2 years, compared to the usual care group, for the PP intervention group, systolic blood pressure was 6 mmHg higher, diastolic blood pressure was 4 mmHg higher and total cholesterol and low-density lipoprotein-cholesterol levels were both 7 mg/dl higher (all P < 0.05). Cost and quality-adjusted life years did not differ between the groups.
CONCLUSIONS: The results of the ECSTATIC study show that an attempt to deprescribe preventive cardiovascular medication in low-CVD-risk patients is safe in the short term when blood pressure and cholesterol levels are monitored after stopping. An attempt to deprescribe medication can be considered, taking patient preferences into consideration.
TRIAL REGISTRATION: This study was registered with Dutch trial register on 20 June 2012 (NTR3493).

BMC Med 2018;16:5