Clinical Briefs: Falls in Rural Elders; Secondary Prevention of CHD; Ramipril in Preventing Stroke
July 15, 2002 4 minutes read
|
Almost half of persons older than 75 years fall each year. When these individuals subsequently fracture a hip, more than half will die within 12 months. Understanding the risk factors associated with falls might lead to opportunities for prevention. To this end, Richardson and colleagues studied a target population (n = 308) of community-dwelling rural elders older than age 65. Each patient responded by self-report to a survey detailing their health status, use of medication(s), and hospitalizations. Their physician then confirmed patient-reported data. Prospective data collection continued for 6 years.
Richardson et al specifically ad-dressed what they termed "intrinsic" risk factors, including age, eyesight, sex, personal health rating, and prescriptions. This is in contradistinction to what were considered "extrinsic" factors, such as a patient who tripped and fell over an object. "Extrinsic" factors were not included in the analysis.
Of the variables analyzed, age and prescription medications were found to influence risk of falls. For instance, falls increased 4% with each increased year of age. Of the potentially modifiable risk factors, analgesics (prescription) and tranquilizers had an adverse effect on fall risk. For instance, analgesics increased fall probability by 55-85%.
Encouragingly, arthritis medications (not defined further in the article) were associated with a decreased risk of falls (20-60%). Enhanced knowledge of risk factor impact on falls may offer opportunity for modulation.
Richardson DR, et al. J Am Board Fam Pract. 2002;15:178-182.
Secondary Prevention of CHD
Aspirin (ASA) for secondary prevention of cardiovascular disease end points has been widely used, based on cumulative experience which suggests that myocardial infarction, stroke, or vascular death may be reduced by as much as 30%. Fortunately, in recent years the vast majority (up to 85%) of post-MI patients have been advised to take ASA at hospital discharge.
Not everyone is able to tolerate ASA, and some persons continue to have vascular events even when taking ASA, prompting clinicians to consider the potential combination of ASA with other antiplatelet agents, such as clopidogrel (CLP). Indeed, the use of CLP in combination with ASA was shown to have superior benefits to ASA alone in studies of persons with acute coronary syndromes, achieving as great as 20% further reduction in cardiovascular end points.
Gaspoz and colleagues used the Coronary Heart Disease Policy Model to assess the comparative cost-effectiveness of ASA, CLP (for ASA ineligible persons), or ASA + CLP over long-range treatment (25 years). For a point of reference, readers are reminded that hypertension treatment, considered a cost-effective intervention, is associated with a cost per quality-adjusted life-year (QALY) of $25-50,000.
In this computer simulation model, ASA was estimated to cost $11,000 per QALY, CLP (for ASA ineligible persons) $31,000, and ASA + CLP $130,000. To use CLP instead of ASA for all antiplatelet prevention opportunities was much less cost effective (> $100,000). Should CLP become substantially reduced in price, its greater efficacy in comparison to ASA could become more attractive. Gaspoz et al conclude that ASA, or CLP in ASA-ineligible persons, are cost-effective. For persons who can tolerate ASA, the addition of CLP was not shown to be favorably cost-effective, despite its demonstrated clinical efficacy.
Gaspoz JM, et al. N Engl J Med. 2002; 346:1800-1806.
Use of Ramipril in Preventing Stroke
Among the first-world nations, stroke remains the second leading cause of death. Encouraging results from trials of hypertension management indicate that control of blood pressure with a variety of agents has a favorable effect, resulting in as much as 40% decrease in stroke, independent of gender or ethnicity. Despite this favorable effect, many stroke victims do not possess blood pressure elevations sufficient to merit antihypertensive treatment by current-day standards. The HOPE trial evaluated almost 10,000 adults age 55 or older who were considered to be at high risk of developing stroke, either due to pre-existing cardiovascular disease (eg, stroke, MI, or angina) or diabetes. Only about half of the population was hypertensive.
This placebo-controlled trial used ramipril (10 mg) daily as treatment. The mean blood pressure change in this trial (3.8/2.8 mm Hg) was modest; this, coupled with the fact that stroke reduction was equivalent in persons who entered the trial with or without hypertension, supports the position that the impact is to some degree independent of blood pressure. Overall, use of ramipril reduced risk of fatal stroke by 61%.
Whether stroke reduction is a "class" effect of ACE inhibitors, or particularly related to ramipril, remains to be determined. In the recently published PROGRESS trial, perindopril, another ACE inhibitor, when used as monotherapy did not reduce stroke.
Bosch J, et al. BMJ. 2002;2:261-264.
Dr. Kuritzky, Clinical Assistant Professor, University of Florida, Gainesville, is Associate Editor of Internal Medicine Alert.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content