Management of Coronary Artery Disease
The recent EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) examined the effect of treatment with the angiotensin-converting enzyme (ACE) inhibitor perindopril in 12,218 patients with stable coronary artery disease (CAD). After 4.2 years, treatment with perindopril 8 mg once daily resulted in a 20% relative risk reduction in the primary end point, a composite of cardiovascular death, non-fatal myocardial infarction, and cardiac arrest (p=0.0003). Risk reductions were also observed for secondary end points, including fatal and non-fatal myocardial infarction (24% reduction, p<0.001) and hospitalisation for heart failure (39% reduction, p=0.002). These benefits were observed on top of standard recommended preventive therapies such as antiplatelet agents, beta blockers and lipid-lowering drugs. Benefits were consistent for all patients with CAD, irrespective of the presence or absence of risk factors such as age, diabetes, hypertension, previous myocardial infarction, or previous revascularisation. Perindopril, a lipophilic tissue ACE inhibitor which binds strongly to ACE, has several anti-atherogenic actions and vascular properties which may contribute to its protective effect. EUROPA is the first trial to show the benefit of ACE inhibition in a broad population often seen in daily clinical practice. The results suggest that perindopril should be added to other recommended preventive treatments in all patients with CAD.
Cardiovascular disease is currently responsible for approximately 16 million deaths yearly, which represents one-third of global deaths, a burden predicted to significantly rise to 37% by 2020. Coronary artery disease (CAD) underlies many of the cardiac manifestations of cardiovascular disease (figure 1). It is the major cause of premature death and disability in the Western world and most European countries. In Europe, CAD alone (i.e. excluding other forms of cardiovascular disease) accounts for approximately two million deaths each year, which represents about half of all deaths from cardiovascular disease. In the UK, CAD is the most common cause of death, accounting for more than 120,000 deaths in 2001. Moreover, CAD not only represents a healthcare burden in its own right (when it is defined as angina or myocardial infarction [MI]) but also contributes to the mortality and morbidity associated with other forms of cardiovascular disease. A study in the UK, for example, concluded that CAD is the single most important aetiology in incident cases of heart failure, accounting for 52% of cases in patients aged < 75 years. In the USA it was estimated that 60% of heart failure cases in the general population might be attributable to CAD.
(Enlarge Image)
The chain of cardiovascular events that can arise from underlying coronary artery disease (CAD)[2]
The costs of CAD in the UK in 1999 were estimated as £1.73 billion: £2.42 billion in informal care, and £2.91 billion in lost productivity (figure 2). Direct and indirect costs of CAD in the USA were estimated as US $129.9 billion in 2003. Unlike diseases which affect predominantly elderly patients, CAD is a prominent cause of death or disability in adults at the peak of their productive lives, when their earning capacity is high; this accounts in part for the heavy economic burden imposed by CAD.
(Enlarge Image)
Expenditure on coronary artery disease per 100,000 persons in selected countries[8]
The recent EUropean trial on Reduction Of cardiac events with Perindopril in stable coronary Artery disease (EUROPA) examined the effect of treatment with the angiotensin-converting enzyme (ACE) inhibitor perindopril in 12,218 patients with stable coronary artery disease (CAD). After 4.2 years, treatment with perindopril 8 mg once daily resulted in a 20% relative risk reduction in the primary end point, a composite of cardiovascular death, non-fatal myocardial infarction, and cardiac arrest (p=0.0003). Risk reductions were also observed for secondary end points, including fatal and non-fatal myocardial infarction (24% reduction, p<0.001) and hospitalisation for heart failure (39% reduction, p=0.002). These benefits were observed on top of standard recommended preventive therapies such as antiplatelet agents, beta blockers and lipid-lowering drugs. Benefits were consistent for all patients with CAD, irrespective of the presence or absence of risk factors such as age, diabetes, hypertension, previous myocardial infarction, or previous revascularisation. Perindopril, a lipophilic tissue ACE inhibitor which binds strongly to ACE, has several anti-atherogenic actions and vascular properties which may contribute to its protective effect. EUROPA is the first trial to show the benefit of ACE inhibition in a broad population often seen in daily clinical practice. The results suggest that perindopril should be added to other recommended preventive treatments in all patients with CAD.
Cardiovascular disease is currently responsible for approximately 16 million deaths yearly, which represents one-third of global deaths, a burden predicted to significantly rise to 37% by 2020. Coronary artery disease (CAD) underlies many of the cardiac manifestations of cardiovascular disease (figure 1). It is the major cause of premature death and disability in the Western world and most European countries. In Europe, CAD alone (i.e. excluding other forms of cardiovascular disease) accounts for approximately two million deaths each year, which represents about half of all deaths from cardiovascular disease. In the UK, CAD is the most common cause of death, accounting for more than 120,000 deaths in 2001. Moreover, CAD not only represents a healthcare burden in its own right (when it is defined as angina or myocardial infarction [MI]) but also contributes to the mortality and morbidity associated with other forms of cardiovascular disease. A study in the UK, for example, concluded that CAD is the single most important aetiology in incident cases of heart failure, accounting for 52% of cases in patients aged < 75 years. In the USA it was estimated that 60% of heart failure cases in the general population might be attributable to CAD.
(Enlarge Image)
The chain of cardiovascular events that can arise from underlying coronary artery disease (CAD)[2]
The costs of CAD in the UK in 1999 were estimated as £1.73 billion: £2.42 billion in informal care, and £2.91 billion in lost productivity (figure 2). Direct and indirect costs of CAD in the USA were estimated as US $129.9 billion in 2003. Unlike diseases which affect predominantly elderly patients, CAD is a prominent cause of death or disability in adults at the peak of their productive lives, when their earning capacity is high; this accounts in part for the heavy economic burden imposed by CAD.
(Enlarge Image)
Expenditure on coronary artery disease per 100,000 persons in selected countries[8]
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