Secondary prevention of coronary heart disease in older patients and the NSF

This study examined the extent of uptake of medication for secondary prevention of coronary heart disease in older British men and women before (1998-2001) and after (2003) the implementation of the national service framework.

Two population based, longitudinal studies of men and women aged 60-79 in 1998-2001, based in one general practice in each of 24 British towns were studied.  Those taking part were men and women with established coronary heart disease at the two time points, aged 60-79 in 1998-2001.

The main outcome measures were the prevalence of use of antiplatelet medication, statins, beta blockers, angiotensin converting enzyme (ACE) inhibitors, and other blood pressure lowering treatments (individually and in combination) assessed in 1998-2001 and 2003.

The study found that between 1998-2001 and 2003, the use of all individual drugs had increased in both men and women, especially for statins (from 34% to 65% in men and from 48% to 67% in women with myocardial infarction). However, less than half received beta blockers and ACE inhibitors, even by 2003. Prevalence of medication use was lower in patients with angina than in those with myocardial infarction. The proportion of patients receiving more than one drug increased over time; by 2003 about half of patients with myocardial infarction and a third of those with angina were receiving antiplatelet medication, statins, and blood pressure lowering treatments.

The authors conclude that between 1998-2001 and 2003, statin uptake and the use of combined drug treatment in elderly men and women increased markedly. However, further potential exists for reducing the risk of recurrent coronary heart disease in older patients, particularly by improving the uptake of medication among angina patients, and by more extensive use of blood pressure lowering treatment (particularly with beta blockers and ACE inhibitors).

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Glucosamine and chondroitin sulfate for osteoarthritis

Glucosamine and chondroitin sulfate are used to treat osteoarthritis. A multicenter, double-blind, placebo- and celecoxib-controlled Glucosamine and chondroitin Arthritis Intervention Trial (GAIT) evaluated their efficacy and safety as a treatment for knee pain from osteoarthritis.

The authors randomly assigned 1583 patients with symptomatic knee osteoarthritis to receive 1500 mg of glucosamine daily, 1200 mg of chondroitin sulfate daily, both glucosamine and chondroitin sulfate, 200 mg of celecoxib daily, or placebo for 24 weeks.

Up to 4000 mg of acetaminophen (paracetamol) daily was allowed as rescue analgesia. Assignment was stratified according to the severity of the knee pain (mild [N=1229] vs. moderate to severe [N=354]). The primary outcome measure was a 20 percent decrease in knee pain from baseline to week 24.

Overall, the study found that glucosamine and chondroitin sulfate were not significantly better than placebo in reducing knee pain by 20 percent. As compared with the rate of response to placebo (60.1 percent), the rate of response to glucosamine was 3.9 percentage points higher (P=0.30), the rate of response to chondroitin sulfate was 5.3 percentage points higher (P=0.17), and the rate of response to combined treatment was 6.5 percentage points higher (P=0.09).

The rate of response in the celecoxib control group was 10.0 percentage points higher than that in the placebo control group (P=0.008). For patients with moderate-to-severe pain at baseline, the rate of response was significantly higher with combined therapy than with placebo (79.2 percent vs. 54.3 percent, P=0.002). Adverse events were mild, infrequent, and evenly distributed among the groups.

In conclusion glucosamine and chondroitin sulfate alone or in combination did not reduce pain effectively in the overall group of patients with osteoarthritis of the knee. Exploratory analyses suggest that the combination of glucosamine and chondroitin sulfate may be effective in the subgroup of patients with moderate-to-severe knee pain.

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Omega 3 and fish

The properties of marine polyunsaturated oils have been linked with several health benefits, including protection from cardiovascular disease. However, a high quality systematic review published in the BMJ (April 1 2006) draws attention to uncertainties about some of the health benefits attributed to omega 3 fats.

The review shows that the evidence for a reduction in cardiovascular events and mortality is less conclusive than we believed. The current review found no strong evidence of a reduction in combined cardiovascular events. The claim that omega 3 fats reduce the risk of cancer is not supported here or by another recent systematic review. For each health outcome there are too few trials with adequate allocation concealment, and too few cohort studies in which the intake of omega 3 fat rather than total fish intake was measured.

Recent findings complicate our understanding of the cardioprotective effect of omega 3 fat. Until the publication of the DART-2 trial in 2003, the evidence showed that omega 3 from oily fish or supplements reduced the risks of fatal myocardial infarction, sudden death, and overall mortality among people with existing disease. DART-2 included 3114 men with stable angina and tested the hypothesis that the main benefit of omega 3 fat is derived from its anti-arrhythmic action in the presence of chronic disease. Surprisingly, DART-2 did not confirm this, showing an excess of sudden and total cardiac deaths. The excess was clearest in participants taking fish oil capsules rather than eating oily fish.

It may be wise to make a distinction between patients with chronic disease such as angina and those with acute myocardial infarction, since in the latter the evidence does support early protection against sudden death.

For the general public some omega 3 fat is probably good for health. Long chain omega 3 fatty acids are structural components of neuronal and other cell membranes. Whether omega 3 fat prevents cognitive impairment and dementia is currently being tested in trials, with the first results expected in 2008.

Adequate intake of omega 3 fats is particularly important for women of childbearing age. However women before and during pregnancy and children under 16 are advised by the UK government to avoid consumption of large predatory fish such as swordfish, which have accumulated a considerable concentration of mercury.

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