As medical journalists, we attempt to be conscientious to try to cover the appropriate clinical studies and updates on practice management considerations from the professional societies that could have direct impact on clinical practice for physicians. However, market trends and real-life registry data show that physicians are quite hesitant to change their practice patterns, in spite of new evidence on better, safer technologies and drugs.
Case in point, the American College of Cardiology recently released data from its outpatient PINNACLE registry, which showed a surprisingly low uptick of dabigatran (Pradaxa, Boehringer Ingelheim Pharmaceuticals) and and rivaroxaban (Xarelto, Bayer HealthCare/Janssen Pharmaceuticals) for stroke prevention in patients with atrial fibrillation (AF).
Warfarin is notoriously difficult to manage, requiring coagulation and frequent lab tests—which is not true with either of the new anticoagulants. Yet, only 12.6 percent of patients on anticoagulants were prescribed either dabigatran or rivaroxaban, according to PINNACLE, which contains records on 250,000 AF patients.
Likewise, the novel antiplatelet drugs— prasugrel (Effient, Eli Lilly/Daiichi Sanyko) and ticagrelor (Brilinta, AstraZeneca) aren’t seeing strong adoption rates. Even with a proven mortality benefit, ticagrelor isn’t gaining much market traffic.
Several thought leaders discussed this phenomenon during CRT.12. “Clinical practice isn’t always driven by what clinical trialers and academicians [say] are important,” said David J. Cohen, MD, of St. Luke’s Mid America Heart Institute in Kansas City, Mo., who offered the uptake of clopidogrel in the late 1990s as an example. “Efficacy didn’t drive this uptake decision; it was about side effects and convenience—once a day, as opposed to twice-daily. This is similar to Pradaxa vs. warfarin decision.”
On the flip side, even when new therapies don’t prove their worth in a trial, some cardiologists still see potential. For example, the findings of HERCULES, the largest, prospective trial assessing renal artery stenting as safe and effective in patients with uncontrolled hypertension and atherosclerotic renal artery stenosis, didn't prove conclusive. Yet, both the study authors and the editorialist recommend that renal stenting for uncontrolled hypertension deserves further attention and trials.
So, have you changed the way you deliver CV care in the past year?