The clinical practice of European cardiologists is directed by the European Society of Cardiology™s guidelines for several clinical entities, in which ├óÔé¼´åİoptimal medical treatment™ (a specific drug regime and lifestyle measures) for each syndrome is defined. The described pharmacotherapy is composed of several drugs, since the clinical research behind the recommendations is conducted using an ├óÔé¼´åİon top of™ strategy. For example, an asymptomatic patient after an acute coronary syndrome with normal ventricular function and without residual ischaemia has an indication to take at least four types of tablets per day, which is difficult to understand and to follow long term. The cost of the drugs is sometimes beyond the patient™s means, which also contributes to lower compliance. A clinician™s practice is usually very busy, which means it is almost impossible to perform patient education and promote adherence to drug therapy and lifestyle changes. Cardiac rehabilitation, as proved by the Global Secondary Prevention Strategies to Limit Event Recurrence after Myocardial Infarction (GOSPEL) study, may be considered the best available secondary prevention programme, as it educates patients and promotes adherence to the optimal medical treatment to a greater degree than usual care.
Coronary artery disease, optimal medical treatment, cardiac rehabilitation, exercise training, secondary prevention, evidence-based medicine, compliance to medical treatment
Disclosure: The author has no conflicts of interest to declare.
Received: 20 November 2010 Accepted: 14 January 2011 Citation: European Cardiology, 2011;7(1):62├óÔé¼ÔÇ£5
Correspondence: Miguel Mendes, Av. Professor Reynaldo dos Santos, 2794-095 Carnaxide, Portugal. E: firstname.lastname@example.org
As far as I know, the designation ├óÔé¼´åİoptimal medical treatment™ was first used by the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial1 investigators as a synonym for the state-of-the-art measures encompassing drug regime, diet and physical activity recommended by the US guidelines for stable angina and acute coronary syndrome (ACS). Looking at the most recent European Society of Cardiology (ESC) guidelines on stable angina2 and ACS with3 or without4 ST elevation, a strict recommendation for antiplatelet medication (acetylsalicylic acid [ASA] alone or in combination with clopidogrel), an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), a beta-blocker and a statin (alone or in combination with ezetimibe) can be found for both subsets (see Table 1).
In the stable angina guideline, optional recommendations for nitrate, amlodipine, nicorandil, molsidomine, ivabradine, trimetazidine and ranolazine, alone or in combination, for angina and a fibrate or nicotinic acid for high-density lipoprotein (HDL) and/or triglyceride control can be found.
The 2008 ESC heart failure guidelines5 recommend a combined approach of a device (cardiac resynchronisation therapy [CRT] and/or implantable cardioverter├óÔé¼ÔÇ£defibrillator [ICD], according to clinical criteria, left ventricular ejection fraction [LVEF] and QRS length), if appropriate, and drug therapy, combining ACE inhibitors, ARBs, aldosterone antagonists and beta-blockers for improved prognosis and symptoms, together with diuretics, digoxin or warfarin for control of symptoms or atrial fibrillation.
In addition to the drug regime recommended in the guidelines, many patients follow prescriptions for additional drugs for diabetes, gout, Parkinson™s or Alzheimer™s disease, osteoporosis and osteoarthritis, and may also take other drugs for associated conditions such as tinnitus, vertigo or glaucoma. Owing to the main disease and associated conditions, many patients are supposed to follow an extensive drug regime that frequently entails taking 20 or more tablets per day.
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