Selection of Medication in Hospitalised Elderly Patients with Angina Pectoris

Objective: To evaluate medication changes in hospitalised elderly patients diagnosed with angina pectoris and to compare the selection of medication with evidence-based treatment guidelines. Design: Review of medical notes and patient interview. Setting: St. Luke’s Hospital, Malta; January May 2001. Subjects: 226 patients, aged 60 years or over, with a history of chronic stable angina and a discharge diagnosis of angina. Main outcome measures: Prevalence of use of antiplatelet agents, lipid lowering agents, beta-blockers, calcium channel blockers, nitrates, potassium channel openers and cellular anti-ischaemic agents; presence of co-morbidities, concurrent medication and adverse effects. Results: Prior to discharge, 77% of patients were receiving antiplatelet agents and 27% were receiving lipid lowering agents. The most frequent anti-ischaemic agents used were nitrates (97%) and second-generation dihydropyridine calcium channel blockers (59%). Beta-blockers were used in 31% of patients and non-dihydropyridine calcium channel blockers were used in 4% of patients. Potassium channel openers (nicorandil) and cellular anti-ischaemic agents (trimetazidine) were used in 5% and 19% of patients respectively. Of patients discharged on a single anti-ischaemic agent, 96% were prescribed nitrates, while 64% of those on two agents were prescribed nitrates and dihydropyridine calcium channel blockers. Beta-blockers, nicorandil and trimetazidine were Marise Gauci BPharm (Hons), MSc Pharmacy Department, University of Malta, Msida, Malta Email: [email protected] Joseph M Cacciottolo MD, DSc Department of Medicine, University of Malta, Msida, Malta Email: [email protected] James C McElnay BSc, PhD School of Pharmacy, The Queen’s University of Belfast, Belfast, Northern Ireland Email: [email protected] generally used in conjunction with at least two other antiischaemic agents. The major medication changes involved the addition, or increase in dose, of amlodipine and isosorbide dinitrate. The major determinants affecting choice of medication were age and co-morbidities. Conclusion: Medication selection for chronic stable angina was not in accordance with treatment guidelines. Introduction Various pharmacological agents are used in the medical management of chronic stable angina pectoris either to alleviate symptoms or to decrease the complications of the disease. There is strong evidence that the use of aspirin reduces the risk of death and recurrent events in patients with coronary artery disease (CAD) and is therefore recommended for all patients in the absence of contraindications. Significant reductions in mortality rate and major coronary events have been demonstrated with the use of statins. Treatment guidelines indicate that the use of statins is warranted when the LDLcholesterol level is greater than 3.0 mmol/L. Beta-blockers have been shown to be effective in the prevention of long-term angina symptoms and in the reduction of cardiovascular morbidity and mortality. Beta-blockers are thus considered as first-line agents in the management of chronic stable angina. Non-dihydropyridine calcium channel blockers such as diltiazem and verapamil are the preferred alternatives when the use of beta-blockers is contraindicated. Although such agents are effective in relieving symptoms, evidence of their effectiveness in reducing morbidity and mortality is limited. Long-acting dihydropyridine calcium channel blockers such as amlodipine are suitable for providing long-term symptomatic relief. Although there is clinical trial evidence for efficacy in symptom control, nitrates have not been shown to reduce mortality in patients with CAD. For this reason, nitrates are no longer considered as the first choice for long-term treatment of chronic stable angina. 2-4 Potassium channel openers have so far been considered as appropriate for symptomatic relief, however, results from a recent large-scale study show significant reductions in morbidity and mortality with the use of nicorandil. Recent guidelines are now recommending angiotensin converting enzyme (ACE) inhibitors in patients with significant CAD (by angiography or previous myocardial infarction (MI)) who also have diabetes and/or left ventricular systolic dysfunction. Cellular anti-ischaemic agents, such as trimetazidine, increase cell tolerance to ischaemia. The place