In older patients with cardiovascular disease, do evidence-based interventions prolong life or decrease cardiovascular events?

First, the good news: Researchers were able, without unusual effort, to apply evidence-based guidelines to older elderly patients with cardiovascular disease (CVD) and achieve goal blood pressure and cholesterol levels in the majority. Now, the bad news: These interventions did not decrease the likelihood of the patients experiencing a cardiovascular problem over the next 3.4 years. The treated patients did not live any longer over this period, and the treatment did not delay deaths. (LOE = 1b)

Strandberg TE, Pitkala KH, Berglind S, Nieminen MS, Tilvis RS. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: The Drugs and Evidence-Based Medicine in the Elderly (DEBATE) study: a randomized, controlled trial. Am Heart J 2006;152:585-592.  [PMID:16923435]

Randomized controlled trial (nonblinded)

Foundation

Concealed

Population-based

To put it bluntly: As we age, if one thing doesn't get us, something else will. That is why it is so important, when evaluating treatments, to look at death from all causes and not just deaths due to the disorder being treated. These Finnish researchers enrolled 400 home-dwelling people between the ages of 75 years and 90 years with CVD. These subjects were randomly selected from the population living in Helsinki. The patients were randomly assigned, using concealed allocation, to receive either usual care from their primary care physician or to receive specialized care based on current evidence-based European guidelines for chronic CVD. The interventions included smoking cessation, adequate nutrition, blood pressure and cholesterol control, prophylactic aspirin, beta-blockers following myocardial infarction, angiotensin-converting enzyme (ACE) inhibitors in patients with heart failure, and anticoagulation in selected patients. The physicians and patients in the study were not blinded to treatment assignment, though researchers who evaluated the outcomes were blinded to treatment assignment. The strength of this study is that the researchers randomly invited patients from the general population to participate, making the results applicable to typical primary care. Over an average 3.4 years, beta-blocker, ACE inhibitor, diuretic, and statin use was significantly higher in the intervention group. Aspirin use was approximately 75% in both groups. Blood pressure and cholesterol control were significantly better in the intervention group. However, patient-oriented outcomes, which were common, were not improved with good treatment. The incidence of myocardial infarction, congestive heart failure, stroke, or cardiovascular death were similar between the 2 groups. Deaths due to any cause occurred at similar rates in both groups (18% vs 17%). The time until a first cardiovascular event did not differ between the 2 groups.