Treatment-risk paradox solved?

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It’s well documented that chronically ill heart patients at highest risk for complications are the least likely to receive prophylactic therapies. Now researchers believe they have found out what’s behind this so-called “treatment-risk paradox.”

Doctors at the University of Alberta in Canada prospectively studied 3,871 patients who had angiography-confirmed CAD. Based on the number, severity, and location of their stenosed arteries, the patients were classified as low-, medium-, or high-risk for poor outcomes. One month after cardiac catheterization, 25.8% of high-risk patients were taking ACE inhibitors, aspirin, and statins, compared with 32.2% of low-risk patients. The most underprescribed therapy, relatively speaking, was statins.

The Alberta researchers were able to dig more deeply than usual into the causes of this paradox because their study was prospective and they documented each patient in great detail, monitoring some 200 variables. They determined that clinicians weren’t withholding therapies because of patients’ race, income level, weight, or other such prejudicial considerations. Rather, they believed the patient was too depressed or otherwise dysfunctional to adhere to medication.

The researchers called this reasoning understandable but faulty. “The benefits of preventive CAD therapies are applicable even to those with poor functional capacity or depression. Our results suggest that these patients should be targeted for more education at discharge and closer follow-up. Even modest increases in prescribing rates for high-risk patients would confer substantial reductions in morbidity and mortality from CAD” (Arch Intern Med. 2007; 167:1019-1025).

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