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Maladies cardiovasculaires: le trio gagnant
Pr Julia Hippisley-Cox (Nottingham, Grande-Bretagne). - BMJ 30/04/2005

Les traitements associant statines, aspirine et bêtabloquants ont permis une réduction de la mortalité de 83%, dans le cadre de cette étude. L'ajout d'un autre type de médicament contre l'hypertension (de la classe des IEC - inhibiteur de l'enzyme de conversion) n'a pas amélioré le résultat, selon les auteurs.

L'étude a porté sur 13.000 patients chez lesquels a été diagnostiqué entre 1996 et 2003 un infarctus, une angine de poitrine ou autre forme de pathologie cardiaque ischémique.
L'évolution des 2.266 patients décédés durant cette période a été comparée à celle de patients d'âge, sexe et année de diagnostic similaires.

L'étude visait notamment à évaluer l'intérêt de différentes associations médicamenteuses alors que l'idée d'une "polypill", associant six médicaments, avait été proposée en 2003 par des chercheurs de l'Université de Londres pour prévenir la survenue de maladies cardiovasculaires chez les plus de 55 ans. [Lire]

Au final, commente un expert dans le BMJ, une thérapie combinée associant deux ou trois médicaments s'avère effectivement "meilleure qu'une monothérapie", mais il s'agit dans ce cas de traiter des patients souffrant déjà d'une maladie cardio-vasculaire et non d'en prévenir l'apparition dans la population comme envisagé avec la "polypill".

Effect of combinations of drugs on all cause mortality in patients with ischaemic heart disease: nested case-control analysis
Julia Hippisley-Cox, professor of clinical epidemiology and general practice1
, Carol Coupland, senior lecturer in medical statistics1 1 Division of Primary Care,
School of Community Health Sciences, University Park, Nottingham NG2 7RD
http://bmj.bmjjournals.com/cgi/content/full/330/7499/1059?ehom

Objective To determine the effect of combinations of statins, aspirin, blockers, and angiotensin converting enzyme inhibitors in the secondary prevention of all cause mortality in patients with ischaemic heart disease.

Design Open prospective cohort study with nested case-control analysis.

Setting 1.18 million patients registered with 89 general practices across 23 strategic health authority areas within the United Kingdom. Practices had longitudinal data for a minimum of eight years and were contributing to QRESEARCH, a new database.

Patients All patients with a first diagnosis of ischaemic heart disease between January 1996 and December 2003. Cases were patients with ischaemic heart disease who died. Controls were patients with ischaemic heart disease who were matched for age, sex, and year of diagnosis and were alive at the time their matched case died.

Main outcome measures Odds ratio with 95% confidence interval for risk of death in cases compared with controls. Exposure was current use of different combinations of statins, aspirin, blockers, and angiotensin converting enzyme inhibitors before death in cases, or the equivalent date in controls.

Results 13 029 patients had a first diagnosis of ischaemic heart disease (incidence rate 338 per 100 000 person years). 2266 cases were matched to 9064 controls. Drug combinations associated with the greatest reduction in all cause mortality were statins, aspirin, and blockers (83% reduction, 95% confidence interval 77% to 88%); statins, aspirin, blockers, and angiotensin converting enzyme inhibitors (75% reduction, 65% to 82%); and statins, aspirin, and angiotensin converting enzyme inhibitors (71% reduction, 59% to 79%). Treatments associated with the smallest reduction in all cause mortality were blockers alone (19% reduction, 37% reduction to 4% increase), angiotensin converting enzyme inhibitors alone (20% reduction, 1% to 35%), and combined statins and angiotensin converting enzyme inhibitors (31% reduction, 57% reduction to 12% increase).

Conclusions Combinations of statins, aspirins, and blockers improve survival in high risk patients with cardiovascular disease, although the addition of an angiotensin converting enzyme inhibitor conferred no additional benefit despite the analysis being adjusted for congestive cardiac failure.
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