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01.12.2018 | Research article | Ausgabe 1/2018 Open Access

BMC Medicine 1/2018

Deprescribing preventive cardiovascular medication in patients with predicted low cardiovascular disease risk in general practice – the ECSTATIC study: a cluster randomised non-inferiority trial

Zeitschrift:
BMC Medicine > Ausgabe 1/2018
Autoren:
Clare H. Luymes, Rosalinde K. E. Poortvliet, Nan van Geloven, Margot W. M. de Waal, Yvonne M. Drewes, Jeanet W. Blom, Nynke Smidt, Willem J. J. Assendelft, Wilbert B. van den Hout, Wouter de Ruijter, Mattijs E. Numans
Wichtige Hinweise

Electronic supplementary material

The online version of this article (doi:https://​doi.​org/​10.​1186/​s12916-017-0988-0) contains supplementary material, which is available to authorized users.

Abstract

Background

The use of cardiovascular medication for the primary prevention of cardiovascular disease (CVD) is potentially inappropriate when potential risks outweigh the potential benefits. It is unknown whether deprescribing preventive cardiovascular medication in patients without a strict indication for such medication is safe and cost-effective in general practice.

Methods

In this pragmatic cluster randomised controlled non-inferiority trial, we recruited 46 general practices in the Netherlands. Patients aged 40–70 years who were using antihypertensive and/or lipid-lowering drugs without CVD and with low risk of future CVD were followed for 2 years. The intervention was an attempt to deprescribe preventive cardiovascular medication. The primary outcome was the difference in the increase in predicted (10-year) CVD risk in the per-protocol (PP) population with a non-inferiority margin of 2.5 percentage points. An economic evaluation was performed in the intention-to-treat (ITT) population. We used multilevel (generalised) linear regression with multiple imputation of missing data.

Results

Of 1067 participants recruited between 7 November 2012 and 18 February 2014, 72% were female. Overall, their mean age was 55 years and their mean predicted CVD risk at baseline was 5%. Of 492 participants in the ITT intervention group, 319 (65%) quit the medication (PP intervention group); 135 (27%) of those participants were still not taking medication after 2 years. The predicted CVD risk increased by 2.0 percentage points in the PP intervention group compared to 1.9 percentage points in the usual care group. The difference of 0.1 (95% CI -0.3 to 0.6) fell within the non-inferiority margin. After 2 years, compared to the usual care group, for the PP intervention group, systolic blood pressure was 6 mmHg higher, diastolic blood pressure was 4 mmHg higher and total cholesterol and low-density lipoprotein-cholesterol levels were both 7 mg/dl higher (all P < 0.05). Cost and quality-adjusted life years did not differ between the groups.

Conclusions

The results of the ECSTATIC study show that an attempt to deprescribe preventive cardiovascular medication in low-CVD-risk patients is safe in the short term when blood pressure and cholesterol levels are monitored after stopping. An attempt to deprescribe medication can be considered, taking patient preferences into consideration.

Trial registration

This study was registered with Dutch trial register on 20 June 2012 (NTR3493).
Zusatzmaterial
Additional file 1: Inclusion and exclusion criteria of the Evaluating Cessation of Statins and Antihypertensive Treatment in Primary Care Trial, as approved by the Medical Ethics Committee of Leiden University Medical Centre. (DOCX 22 kb)
12916_2017_988_MOESM1_ESM.docx
Additional file 2: Deprescribing guideline. Table S1. Examples of dose-lowering schemes. (DOCX 18 kb)
12916_2017_988_MOESM2_ESM.docx
Additional file 3: Cost-effectiveness analysis. Table S2. Costs (in £) for the preparation of the intervention, per selected patient. Table S3. Costs (in £) and QALYs per patient in usual care group and intervention group. Figure S1. EuroQol Utility at t = 0, t = 3, t = 6, t = 12 and t = 24 in the usual care group and the intention. Figure S2. Cost-effectiveness acceptability curve showing the probability that an attempt to deprescribe preventive cardiovascular medication is cost-effective compared to usual care. (DOCX 66 kb)
12916_2017_988_MOESM3_ESM.docx
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