Drugs & Aging

, Volume 20, Issue 8, pp 585–595

Benefits of Optimising Drug Treatment in Home-Dwelling Elderly Patients with Coronary Artery Disease

  • Timo E. Strandberg
  • Kaisu H. Pitkala
  • Reijo S. Tilvis
Review Article
  • 21 Downloads

Abstract

Coronary artery disease (CAD) is prevalent in the elderly and often leads to disability. Consequently, strategies for optimising the prevention and treatment of CAD in the elderly are important from both the individual and societal perspectives.

Although it is common knowledge that the elderly are heavy consumers of drugs, there is evidence to show that there is under-prescribing of evidence-based medical therapies in the home-dwelling elderly coronary patient and there may be overuse of some non-evidence-based (antioxidants) and purely symptomatic treatments. In particular, aspirin (acetylsalicylic acid), β-adrenoceptor antagonists, ACE inhibitors and HMG-CoA reductase inhibitors are under-utilised. Although the evidence base is largely drawn from trials including patients younger than 75 years, it is reasonable to assume that the data applies to patients aged over 75 years and that better use of evidence-based medicines would provide benefits to the home-dwelling aged patient.

Evidence from the few multifactorial studies available suggest possible benefits including reduction of cardiovascular events, less disability and better quality of life in old age. At the societal level, this would be reflected in fewer hospitalisations and institutionalisations, which means decreased cost of elderly care.

References

  1. 1.
    Murray CJL, Lopez AD. Regional patterns of disability-free life expectancy and disability-adjusted life expectancy: Global Burden of Disease Study. Lancet 1997; 349: 1347–52PubMedCrossRefGoogle Scholar
  2. 2.
    Lloyd-Jones DM, Larson MG, Beiser A, et al. Lifetime risk of developing coronary heart disease. Lancet 1999; 353: 89–92PubMedCrossRefGoogle Scholar
  3. 3.
    Williams MA, Fleg JL, Ades PA, et al. Secondary prevention of coronary heart disease in the elderly (with emphasis on patients ≥ 75 years of age. An American Heart Association Scientific Statement from the Council on Clinical Cardiology Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention. Circulation 2002; 105: 1735–43PubMedCrossRefGoogle Scholar
  4. 4.
    Pinsky JL, Jette AM, Branch LG, et al. The Framingham Disability Study: relationships of various coronary heart disease manifestations to disability in older persons living in the community. Am J Public Health 1990; 80: 1363–8PubMedCrossRefGoogle Scholar
  5. 5.
    Rickenbacher P, Pfisterer M. TIME has come to have a closer look at the management of cardiovascular disease in the elderly. Eur Heart J 2002; 23: 993–5PubMedCrossRefGoogle Scholar
  6. 6.
    Staessen JA, Gasowski J, Wang JG, et al. Risks of untreated and treated isolated systolic hypertension in the elderly: meta-analysis of outcome trials. Lancet 2000; 355: 865–72PubMedCrossRefGoogle Scholar
  7. 7.
    Miettinen TA, Pyörälä K, Olsson AG, et al. Cholesterol-lowering therapy in women and elderly patients with myocardial infarction or angina pectoris: findings from the Scandinavian Simvastatin Survival Study (4S). Circulation 1997; 96: 4211–8PubMedCrossRefGoogle Scholar
  8. 8.
    Lewis SJ, Moye LA, Sacks FM, et al. Effect of pravastatin on cardiovascular events in older patients with myocardial infarction and cholesterol levels in the average range: results of the Cholesterol and Recurrent Events (CARE) trial. Ann Intern Med 1998; 129: 681–9PubMedGoogle Scholar
  9. 9.
    Hunt D, Young P, Simes J, et al. Benefits of pravastatin on cardiovascular events and mortality in older patients with coronary heart disease are equal to or exceed those seen in younger patients: results from the LIPID trial. Ann Intern Med 2001; 134: 931–40PubMedGoogle Scholar
  10. 10.
    Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk individuals: a randomised placebo-controlled trial. Lancet 2002; 360: 7–22CrossRefGoogle Scholar
  11. 11.
    Lee PY, Alexander KP, Hammill BG, et al. Representation of elderly persons and women in published randomized trials of acute coronary syndromes. JAMA 2001; 286: 708–13PubMedCrossRefGoogle Scholar
  12. 12.
    Heiat A, Gross CP, Krumholz HM. Representation of the elderly, women, and minorities in heart failure trials. Arch Intern Med 2002; 162: 1682–8PubMedCrossRefGoogle Scholar
  13. 13.
    Tsevat J, Dawson NV, Wu AW, et al. Health values of hospitalized patients 80 years or older. JAMA 1998; 279: 371–5PubMedCrossRefGoogle Scholar
  14. 14.
    Laakkonen ML, Pitkala K, Strandberg TE, Tilvis RS. Resuscitation preferences related to attitudes towards life in an aged population [abstract]. 16 Nordiske Kongres i Gerontologi; 2002 May 25–28; Aarhus, DenmarkGoogle Scholar
  15. 15.
    Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med 1980; 303: 130–5PubMedCrossRefGoogle Scholar
  16. 16.
    Vita JA, Terry RB, Hubert HB, et al. Aging, health risks, and cumulative disability. N Engl J Med 1998; 338: 1035–41PubMedCrossRefGoogle Scholar
  17. 17.
    Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States. JAMA 2002; 288: 3137–46PubMedCrossRefGoogle Scholar
  18. 18.
    Fries JF. Reducing disability in older age. JAMA 2002; 288: 3164–6PubMedCrossRefGoogle Scholar
  19. 19.
    Mosterd A, Reitsma JB, Grobbee DE. Angiotensin converting enzyme inhibition and hospitalisation rates for heart failure in the Netherlands, 1980 to 1999: the end of an epidemic? Heart 2002; 87: 75–6PubMedCrossRefGoogle Scholar
  20. 20.
    Wood D, De Backer G, Faergeman O, et al. Prevention of coronary heart disease in clinical practice: recommendations of the Second Joint Task Force of European and other Societies on coronary prevention. Eur Heart J 1998; 19: 1434–503CrossRefGoogle Scholar
  21. 21.
    Aronow WS. Management of older persons after myocardial infarction. J Am Geriatr Soc 1998; 46: 1459–68PubMedGoogle Scholar
  22. 22.
    Aronow WS. Treatment of the elderly post-myocardial infarction patient. Am J Geriatr Cardiol 2001; 10: 316–22, 376PubMedCrossRefGoogle Scholar
  23. 23.
    Wilson SH, Kennedy FP, Garratt KN. Optimisation of the management of patients with coronary heart disease and type 2 diabetes mellitus. Drugs Aging 2001; 18: 325–33PubMedCrossRefGoogle Scholar
  24. 24.
    Antithrombotic Trialists. Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients. BMJ 2002; 324: 71–86CrossRefGoogle Scholar
  25. 25.
    Derry S, Loke YK. Risk of gastrointestinal haemorrhage with long term use of aspirin: meta-analysis. BMJ 2000; 321: 1183–7PubMedCrossRefGoogle Scholar
  26. 26.
    Lai KC, Lam SK, Chu KM, et al. Lansoprazole for the prevention of recurrences of ulcer complications from long-term low-dose aspirin use. N Engl J Med 2002; 346(26): 2033–8PubMedCrossRefGoogle Scholar
  27. 27.
    Gum PA, Kottke-Marchant K, Poggio ED, et al. Profile and prevalence of aspirin resistance in patients with cardiovascular disease. Am J Cardiol 2001; 88: 230–5PubMedCrossRefGoogle Scholar
  28. 28.
    Aviles RJ, Bhatt DL. Antiplatelet therapies in combination for the treatment of patients with stable and unstable coronary artery disease. J Thromb Thrombolysis 2002; 13: 177–82PubMedCrossRefGoogle Scholar
  29. 29.
    Anand SS, Yusuf S. Oral anticoagulant therapy in patients with coronary artery disease: a meta-analysis. JAMA 1999; 282: 2058–67PubMedCrossRefGoogle Scholar
  30. 30.
    Catella-Lawson F, Reilly MP, Kapoor SC, et al. Cycloox-ygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med 2001; 345: 1809–17PubMedCrossRefGoogle Scholar
  31. 31.
    Ahmed A. Interaction between aspirin and angiotensin-con-verting enzyme inhibitors: should they be used together in older adults with heart failure? J Am Geriatr Soc 2002; 50: 1293–6PubMedCrossRefGoogle Scholar
  32. 32.
    Bucher HC, Griffith LE, Guyatt GH. Systematic review on the risk and benefit of different cholesterol-lowering interventions. Arterioscler Thromb Vasc Biol 1999; 19: 187–95PubMedCrossRefGoogle Scholar
  33. 33.
    Athyros VG, Papageorgiou AA, Mercouris RB, et al. Treatment with atorvastatin to the National Cholesterol Educational Program goal versus “usual” care in secondary coronary heart disease prevention. The Greek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) Study. Curr Med Res Opin 2002; 18: 220–8PubMedCrossRefGoogle Scholar
  34. 34.
    Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003; 361: 1149–58PubMedCrossRefGoogle Scholar
  35. 35.
    Serruys PW, de Feyter P, Macaya C, et al. Fluvastatin for prevention of cardiac events following successful first percutaneous coronary intervention: a randomized controlled trial. JAMA 2002; 287: 3215–22PubMedCrossRefGoogle Scholar
  36. 36.
    Shepherd J, Cobbe SM, Ford I, et al. Prevention of coronary heart disease with pravastatin in men with hypercholester-olemia. N Engl J Med 1995; 333: 1301–7PubMedCrossRefGoogle Scholar
  37. 37.
    Downs JR, Clearfield M, Weis S, et al. Primary prevention of acute coronary events with lovastatin in men and women with avarage cholesterol levels. JAMA 1998; 279: 1615–22PubMedCrossRefGoogle Scholar
  38. 38.
    Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study Group (4S). Lancet 1994; 344: 1383–9Google Scholar
  39. 39.
    Sacks FM, Pfeffer MA, Moye LA, et al. The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996; 335: 1001–9PubMedCrossRefGoogle Scholar
  40. 40.
    Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998, 57Google Scholar
  41. 41.
    Shepherd J, Blauw GJ, Murphy MB, et al. Pravastatin in elderly individuals at risk of vascular disease (PROSPER); a randomised controlled trial. Lancet 2002; 360: 1623–30PubMedCrossRefGoogle Scholar
  42. 42.
    Aronow WS, Ahn C. Incidence of new coronary events in older persons with prior myocardial infarction and serum low-density lipoprotein cholesterol ≥125 mg/dl treated with statins versus no lipid-lowering drugs. Am J Cardiol 2002; 89: 67–9PubMedCrossRefGoogle Scholar
  43. 43.
    Johannesson M, Jonsson B, Kjekshus J, et al. Cost effectiveness of simvastatin treatment to lower cholesterol levels in patients with coronary heart disease. Scandinavian Simvastatin Survival Study Group. N Engl J Med 1997; 336: 332–6PubMedCrossRefGoogle Scholar
  44. 44.
    Wolozin B, Killman W, Rousseau P, et al. Decreased prevalence of Alzheimer disease associated with HMG CoA reduc-tase inhibitors. Arch Neurol 2000; 57: 1439–43PubMedCrossRefGoogle Scholar
  45. 45.
    Jick H, Zornberg GL, Jick SS, et al. Statins and the risk of dementia. Lancet 2000; 356: 1627–31PubMedCrossRefGoogle Scholar
  46. 46.
    Rockwood K, Kirkland S, Hogan DB, et al. Use of lipid-lowering agents, indication bias, and the risk of dementia in community-dwelling elderly people. Arch Neurol 2002; 59: 223–7PubMedCrossRefGoogle Scholar
  47. 47.
    Bucher HC, Griffith LE, Guyatt GH. Effect of HMGcoA reduc-tase inhibitors on stroke. Ann Intern Med 1998; 128: 89–95PubMedGoogle Scholar
  48. 48.
    Simons M, Keller P, Dichgans J, et al. Cholesterol and Alzheimer’s disease: is there a link? Neurology 2001; 57: 1089–93PubMedCrossRefGoogle Scholar
  49. 49.
    Locatelli S, Lutjohann D, Schmidt HHJ, et al. Reduction of plasma 24S-hydroxycholesterol (cerebrosterol) levels using high dosage simvastatin in patients with hypercholesterolemia. Arch Neurol 2002; 59: 213–6PubMedCrossRefGoogle Scholar
  50. 50.
    Marx J. Bad for the heart, bad for the mind? Science 2001; 294: 508–9PubMedCrossRefGoogle Scholar
  51. 51.
    Grundy SM. Statin therapy in older persons. Arch Intern Med 2002; 162: 1329–31PubMedCrossRefGoogle Scholar
  52. 52.
    Whincup PH, Emberson JR, Lennon L, et al. Low prevalence of lipid lowering drug use in older men with established coronary heart disease. Heart 2002; 88: 25–9PubMedCrossRefGoogle Scholar
  53. 53.
    Benner JS, Glynn RJ, Mogun H, et al. Long-term persistence in use of statin therapy in elderly patients. JAMA 2002; 288: 455–61PubMedCrossRefGoogle Scholar
  54. 54.
    Jackevicius CA, Mamdani M, Tu JV. Adherence with statin therapy in elderly patients with and without acute coronary syndromes. JAMA 2002; 288: 462–7PubMedCrossRefGoogle Scholar
  55. 55.
    Pasternak RC, Smith SC, Bairey-Merz CN, et al. ACC/AHA/NHLBI clinical advisory on the use and safety of statins. Circulation 2002; 106: 1024–8PubMedCrossRefGoogle Scholar
  56. 56.
    Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol: Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group. N Engl J Med 1999; 341: 410–8PubMedCrossRefGoogle Scholar
  57. 57.
    Rubins HB, Davenport J, Babikian V, et al. Reduction in stroke with gemfibrozil in men with coronary heart disease and low HDL cholesterol: the Veterans Affairs HDL Intervention Trial (VA-HIT). Circulation 2001; 103: 2828–33CrossRefGoogle Scholar
  58. 58.
    Faggiotto A, Paoletti R. Statins and blockers of the renin-angiotensin system. Hypertension 1999; 34: 987–96PubMedCrossRefGoogle Scholar
  59. 59.
    Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342: 145–53PubMedCrossRefGoogle Scholar
  60. 60.
    Bosch J, Yusuf S, Pogue J, et al. Use of ramipril in preventing stroke: double blind randomised trial. BMJ 2002; 324: 699–702PubMedCrossRefGoogle Scholar
  61. 61.
    Schrader J, Luders S. Preventing stroke. BMJ 2002; 324: 687–8PubMedCrossRefGoogle Scholar
  62. 62.
    Ahmed A, Kiefe CI, Allman RM, et al. Survival benefits of angiotensin-converting enzyme inhibitors in older heart failure patients with perceived contraindications. J Am Geriatr Soc 2002; 50: 1659–66PubMedCrossRefGoogle Scholar
  63. 63.
    Dahlöf B, Devereux R, Kjeldsen SE, et al. Cardiovascular morbidity and mortality in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359: 995–1003PubMedCrossRefGoogle Scholar
  64. 64.
    Hansson L, Lithell H, Skoog I, et al. Study on Cognition and Prognosis in the Elderly (SCOPE): baseline characteristics. Blood Press 2000; 9: 146–51PubMedCrossRefGoogle Scholar
  65. 65.
    Freemantle N, Cleland J, Young P, et al. Beta blockade after myocardial infarction: systematic review and meta regression analysis. BMJ 1999; 318: 1730–7PubMedCrossRefGoogle Scholar
  66. 66.
    Park KC, Forman DE, Wei JY. Utility of beta-blockade treatment for older postinfarction patients. J Am Geriatr Soc 1995; 43: 751–5PubMedGoogle Scholar
  67. 67.
    Bristow MR. Beta-adrenergic receptor blockade in chronic heart failure. Circulation 2000; 101: 558–69PubMedCrossRefGoogle Scholar
  68. 68.
    Rochon PA, Gurwitz JH. Prescribing for seniors. Neither too much nor too little. JAMA 1999; 282: 113–5PubMedCrossRefGoogle Scholar
  69. 69.
    Krumholz HM, Radford MJ, Wang Y, et al. National use and effectiveness of beta-blockers for the treatment of elderly patients after acute myocardial infarction. JAMA 1998; 280: 623–9PubMedCrossRefGoogle Scholar
  70. 70.
    Strandberg TE, Pitkala K, Kulp S, et al. Use of cardiovascular drugs by home-dwelling coronary patients aged 75 years and older. Eur J Clin Pharmacol 2001; 57: 513–6PubMedCrossRefGoogle Scholar
  71. 71.
    Ghosh S, Ziesmer V, Aronow WS. Underutilization of aspirin, beta blockers, angiotensin-converting enzyme inhibitors, and lipid-lowering drugs and overutilization of calcium channel blockers in older persons with coronary artery disease in an academic nursing home. J Gerontol A Biol Sci Med Sci 2002; 57: M398–400PubMedCrossRefGoogle Scholar
  72. 72.
    Ko DT, Hebert PR, Coffey CS, et al. Beta-blocker treatment and symptoms of depression, fatigue, and sexual dysfunction. JAMA 2002; 288: 351–7PubMedCrossRefGoogle Scholar
  73. 73.
    Dahlof B, Lindholm LH, Hansson L, et al. Morbidity and mortality in the Swedish Trial in Old Patients with Hypertension. (STOP-Hypertension). Lancet 1991; 338: 1281–5PubMedCrossRefGoogle Scholar
  74. 74.
    Staessen JA, Fagard R, Thijs L, et al. Randomized double blind comparison of placebo and active treatment for older patients with systolic hypertension. Lancet 1997; 350: 757–64PubMedCrossRefGoogle Scholar
  75. 75.
    Abrams J. Nitrates. Med Clin North Am 1988; 72: 1–35PubMedGoogle Scholar
  76. 76.
    Steinberg D, Witztum JL. Is the oxidative modification hypothesis relevant to human atherosclerosis? Do the antioxidant trials conducted to date refute the hypothesis? Circulation 2002; 105: 2107–11PubMedCrossRefGoogle Scholar
  77. 77.
    Wald DS, Law M, Morris JK. Homocysteine and cardiovascular disease: evidence on causality from a meta-analysis. BMJ 2002; 325: 1202–9PubMedCrossRefGoogle Scholar
  78. 78.
    Homocysteine Studies Collaboration. Homocysteine and risk of ischemic heart disease and stroke: a meta-analysis. JAMA 2002; 288: 2015–22CrossRefGoogle Scholar
  79. 79.
    Ray WA, Stein M, Hall K, et al. Non-steroidal anti-inflammatory drugs and risk of serious coronary heart disease: an observational cohort study. Lancet 2002; 359: 118–23PubMedCrossRefGoogle Scholar
  80. 80.
    Pitkala KH, Strandberg TE, Tilvis RS. Worsening heart failure associated with COX-2 inhibitors. Am J Med 2002; 112: 424–6PubMedCrossRefGoogle Scholar
  81. 81.
    Catella-Lawson F, Crofford LJ. Cyclooxygenase inhibition and thrombogenicity. Am J Med 2001; 110: 28S–32SPubMedCrossRefGoogle Scholar
  82. 82.
    Bing RJ, Lomnicka M. Why do cyclo-oxygenase-2 inhibitors cause cardiovascular events? J Am Coll Cardiol 2002; 39: 521–2PubMedCrossRefGoogle Scholar
  83. 83.
    Mukherjee D. Selective cyclooxygenase-2 (COX-2) inhibitors and potential risk of cardiovascular events. Biochem Pharmacol 2002; 63: 817–22PubMedCrossRefGoogle Scholar
  84. 84.
    Wills P, Fastbom J, Claesson CB, et al. Use of cardiovascular drugs in an older Swedish population. J Am Geriatr Soc 1996; 44: 54–60PubMedGoogle Scholar
  85. 85.
    Emeriau JP, Fourrier A, Dartigues JF, et al. Drug use in the elderly. Bull Acad Natl Med 1998; 182: 1419–29PubMedGoogle Scholar
  86. 86.
    Giron MST, Claesson C, Thorslund M, et al. Drug use pattern in a very elderly population. Clin Drug Invest 1999; 17: 389–98CrossRefGoogle Scholar
  87. 87.
    Barat I, Andreasen F, Damsgaard EMS. The consumption of drugs by 75-year-old individuals living in their own homes. Eur J Clin Pharmacol 2000; 56: 501–9PubMedCrossRefGoogle Scholar
  88. 88.
    Simiand-Erdociain E, Lapeyre-Mestre M, Bagheri-Charabiani H, et al. Drug consumption in a very elderly community-dwelling population. Eur J Clin Pharmacol 2001; 57: 691–2PubMedCrossRefGoogle Scholar
  89. 89.
    Ebrahim S. The medicalisation of old age: should be encouraged. BMJ 2002; 324: 861–4PubMedCrossRefGoogle Scholar
  90. 90.
    Gurwitz JH, Rochon P. Improving the quality of medication use in elderly patients: a not-so-simple prescription. Arch Intern Med 2002; 162: 1670–2PubMedCrossRefGoogle Scholar
  91. 91.
    EUROASPIRE II Study Group. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries; principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J 2001; 22: 554–72CrossRefGoogle Scholar
  92. 92.
    Boult C, Boult LB, Morishita L, et al. A randomized clinical trial of outpatient geriatric evaluation and management. J Am Geriatr Soc 2001; 49: 351–9PubMedCrossRefGoogle Scholar
  93. 93.
    Hebert R, Robichaud L, Roy PM, et al. Efficacy of a nurse-led multidimensional preventive programme for older people at risk of functional decline: a randomized controlled trial. Age Ageing 2001; 30: 147–53PubMedCrossRefGoogle Scholar
  94. 94.
    McAlister FA, Lawson FME, Teo KK, et al. Randomised trials of secondary prevention programmes in coronary heart disease: systematic review. BMJ 2001; 323: 957–62PubMedCrossRefGoogle Scholar
  95. 95.
    Pasquali SK, Alexander KP, Peterson ED. Cardiac rehabilitation in the elderly. Am Heart J 2001; 142: 748–55PubMedCrossRefGoogle Scholar
  96. 96.
    Naylor MD, Brooten D, Jones R, et al. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med 1994; 120: 999–1006PubMedGoogle Scholar
  97. 97.
    Naylor MD, Brooten D, Campbell R, et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA 1999; 281: 613–20PubMedCrossRefGoogle Scholar
  98. 98.
    Campbell NC, Thain J, Deans HG, et al. Secondary prevention clinics for coronary heart disease: randomised trial of effect on health. BMJ 1998; 316: 1434–7PubMedCrossRefGoogle Scholar
  99. 99.
    Campbell NC, Ritchie LD, Thain J, et al. Secondary prevention in coronary heart disease: randomised trial of nurse led clinics in primary care. Heart 1998; 80: 447–52PubMedGoogle Scholar
  100. 100.
    Strandberg TE, Pitkälä K, Bergling S, et al. Multifactorial cardiovascular disease prevention in patients aged 75 years and older: a randomized controlled trial. Am Heart J 2001; 142: 945–51PubMedCrossRefGoogle Scholar
  101. 101.
    Strandberg TE, Pitkälä K, Berglind S, et al. Possibilities of multifactorial cardiovascular disease prevention in patients aged 75 and older: a randomized, controlled trial. Drugs and Evidence Based Medicine in the Elderly (DEBATE) Study. Eur Heart J 2003. In pressGoogle Scholar

Copyright information

© Adis Data Information BV 2003

Authors and Affiliations

  • Timo E. Strandberg
    • 1
  • Kaisu H. Pitkala
    • 1
  • Reijo S. Tilvis
    • 1
  1. 1.Department of Medicine, Geriatric ClinicUniversity of HelsinkiHelsinkiFinland

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