Eligibility and Preventive Potential for New Evidence-Based Cardiovascular Drugs in Secondary Prevention

Key PointsQuestionHow many patients are eligible for the 12 novel cardiovascular preventive therapies introduced in recent years and what are their preventive potential among secondary prevention patients? FindingThis cohort study included 6292 patients with known ischemic heart disease and 2277 patients with prior myocardial infarction from the Copenhagen General Population Study. Most patients with known ischemic heart disease (8 of 10) or myocardial infarction (10 of 10) were eligible to receive novel preventive therapies. MeaningThis study raises questions for the cardiovascular community about access to these potentially expensive therapies, including strategies for prioritizing their use. ImportanceRecently, 12 randomized clinical trials (RCTs) have demonstrated the efficacy of novel therapies for mainly secondary prevention of atherosclerotic cardiovascular disease. However, given the potential overlapping eligibility of the RCTs, along with the cost of the new therapies, there are uncertainty and questions about implementing these RCT findings in real-world clinical practice. ObjectiveTo determine the eligibility and preventive potential for these new preventive therapies in a contemporary population. Design, Setting, and ParticipantsThis population-based contemporary cohort study included 6292 patients with known ischemic heart disease (IHD) and 2277 with a previous myocardial infarction (MI) enrolled between November 2003 and February 2015. Analyses were performed in the Copenhagen General Population Study with a mean (SD) of 7.7 (3.5) years of follow-up. The data were analyzed between January and October 2019. Main Outcomes and MeasuresWe determined the drug eligibility and evidence-based potential for preventing major cardiovascular events of the 12 cardiovascular drugs tested in the following recent RCTs: IMPROVE-IT, PEGASUS, EMPA-REG, LEADER, SUSTAIN-6, FOURIER, CANVAS, REVEAL, CANTOS, COMPASS, ODYSSEY-OUTCOMES, and REDUCE-IT. The analyses were performed in patients with known IHD or with a previous MI at baseline. ResultsOf 6292 participants, 3861 (61%) were men and the mean (interquartile range) age was 69 (62-76) years. In patients with IHD or MI at baseline, eligibility for 1 or more new medications was 80% (n=5036) and 99% (n=2273), respectively, by meeting RCT enrollment criteria. Dividing the new therapies into 4 drug classes (lipid-modifying, antithrombotic, anti-inflammatory, and antidiabetic drugs), 2594 and 1834 patients with IHD or MI (41% and 81%, respectively) were eligible for 2 or more drug classes simultaneously. The 5-year estimated percentage of major cardiovascular events that could be prevented for each new therapy was 1% to 20% in patients with IHD or MI at baseline. Conclusions and RelevanceMost patients with known IHD or previous MI are eligible for additional new secondary prevention therapies. This raises questions for the cardiovascular community and health care authorities about access to these potentially expensive therapies, including strategies for prioritizing their use. This cohort study examines the drug eligibility of 12 cardiovascular drugs recently tested in several randomized clinical trials for Danish patients with known ischemic heart disease or prior myocardial infarction.