The issue of under-treatment of patients at risk for cardiovascular disease was again highlighted in a study published in the January 14 2003 Annals of Internal Medicine. This report demonstrated that drug treatments that have been unquestionably beneficial are not being prescribed in the prevention another heart attack in patients who have suffered a first event, but even in the prevention of the first event in patients at risk. Moreover, there seems to be a disproportionate number of women who are not getting the treatments. What is particularly irksome is that many of the clinical trials have shown that women benefit even more than men when given these therapies.

This particular study involved almost 2800 postmenopausal women who had documented coronary artery disease. Despite having no contraindications for a given medication class, potentially life-saving medications like statins, beta-blockers and even aspirin were prescribed in alarmingly low percentages in otherwise eligible patients. The number of events, and more importantly lives, saved when extrapolated to the total population at risk, is significant when one realizes that each of these drug classes has been shown to reduce subsequent events by 20-30%.

The reasons for this discrepancy may go back to the discredited bias that heart disease is a man's disease. Indeed, since the mid 1980s, there are more American women with heart attacks annually than men, although the heart attacks tend to occur when women are older.

Women tend to have less typical symptoms of heart disease, so they tend to get non-cardiac diagnoses, such as gastrointestinal diagnoses when they see their doctors. But as this study demonstrated, even when the diagnosis is clearly established, women still get under-treated.

One would think that the pervasive guidelines that have been developed to help healthcare providers identify and treat patients at risk would have solved much of this. Although helpful, these documents have not been as useful since they often sit on the doctor's desk or the walls of the examination room.

My disease management presentations to colleagues and the healthcare industry have emphasized that accountability is the difference between having guidelines and using guidelines. To whom one is accountable makes little difference in my estimation. It may be as threatening as the federal government or the health plan, but as reasonable as you, the patient. If the patient simply asks the doctor if they are being treated to guideline standards derived by consensus expert panels, the doctor will have to either say yes, or look them up. Better, the patient should research what those guidelines are as a back-up plan. Doctors should not be threatened by this behavior, since the person at risk is on the other side of the desk. The odds of getting the best treatment, or an explanation of why those guidelines do not apply, are all positive results of this proactive maneuver. If the doctor gets upset, get another doctor.

A couple of other caveats may be useful here. Lifestyle changes should not be minimized. Often, the dosages of medications can be minimized if one has adopted nutritional, exercise and weight management interventions. This is particularly true in patients who are at risk, but who have not had any overt cardiac event. Once an event has occurred, medications may be unavoidable since other benefits of drug therapy have been documented in order to stabilize the disease processes.

Another caveat is the dollars. All drug treatments cost money to someone. The cost may be borne by the health plan, the pharmacy benefit manager, the patient, or all of the above. Using the best proven medications may be more expensive than some of the players wish to accept. Alternates may be acceptable, but that decision must be predicated on factors other than cost alone. Evidence-based medicine still involves the calculus of probability and odds of benefit. For that, you have to rely on your doctor and your own research. Ask questions, because the doctor works for you.