- Email: [email protected]
Drugs for the heart
Perspectives
For the Jupiter trial see N Engl J Med 2008; 359: 2195–2207 DOI:10.1056/ NEJMoa0807646
Thanks to the greater efficacy of the statins it was now possible to show in controlled clinical trials that these drugs were equally effective in men and in women; in the old and in the young, in people with diabetes and in the non-diabetic. Larger doses were used to reduce LDL cholesterol concentrations to unprecedented new lows—for example, last year’s JUPITER study of rosuvastatin reported that mean LDL concentrations fell by almost 50% in the treatment group and hard primary endpoints were reduced by 44%. The statins have already earned their place alongside quinine, aspirin, and penicillin as drugs that revolutionised medicine. Preventive cardiology now competes successfully with cardiac catheterisation and revascularisation. In Triumph of the Heart, Li, who was a key player in the group at Parke-Davis
that developed atorvastatin (Lipitor), focuses on the ways in which the pharmaceutical industry responded to Endo’s discovery. Roger Newton headed the team and Li was the medicinal chemist. His book offers valuable insights into the way a drug company goes about building a platform for a potential “blockbuster”. Although Lipitor was the fifth statin to reach market, it quickly jumped into first place. Annual sales ultimately topped US$12 billion per year in 2007, making it the best-selling drug in history. Have we gone as far as we can go? I think not. The reduction in fatal and non-fatal infarction in statin trials to date has averaged 30–35% and that is quite remarkable. However, I think the results of these trials underestimate the ultimate potential of the statins. First of all, the trials have mostly run the canonical 5 years; results of longer-
term treatment may well be even more impressive. Second, almost all the studies have used monotherapy; we know we can lower LDL concentrations more effectively with combined drug treatment and we know that the results support the position of those who say “the lower the better”. Finally, the trials to date have dealt mostly with people aged 60 years and older— ie, people who already have advanced arterial lesions—predictably results will be more impressive if we intervene earlier, when the lesions are less advanced and possibly more readily reversible. The story of the statins is not over; the best is yet to come.
Daniel Steinberg [email protected] DS is the author of The Cholesterol Wars: the Skeptics vs the Preponderance of Evidence (Academic Press/Elsevier, 2007).
In brief Book Drugs for the heart
Drugs for the Heart, 7th Edition Expert Consult: Online and Print Lionel H Opie, Bernard J Gersh. Saunders/Elsevier, 2009. Pp 512. US$64·95. ISBN 978-1-4160-6158-8.
The Lancet is published by Elsevier Ltd.
518
I feel like a dinosaur. I’m surrounded by electronic blather. My hometown newspaper is going online, which to me means away. The paper journal that I used to edit is now electronic. The residents and medical students that I teach are “connected” all the time. Several of them don’t even own a textbook. Are there any books left? Well, are there? The answer is a resounding yes. I got my Drugs for the Heart, 7th Edition, by Lionel Opie and Bernard Gersh, the other day and smiled all the way home. I am not yet extinct after all. Oh, I know that the book is also available online—no doubt my residents and students will be delighted with that version—but I like the paper version. Packed with useful information, this book is smaller than my laptop, mercifully bigger than my Blackberry, and infinitely navigable in 12 lucid and
straightforward chapters. Everything you need to know about drugs for the heart is here: β blockers; nitrates; calcium channel blocking drugs; diuretics; inhibitors of the renin-angiotensin system; drugs for heart failure; antihypertensives; antiarrhythmics; antithrombotics; drugs for lipids, metabolic syndromes, and diabetes; and when to use each drug. The book has the clearest figures and tables that I have ever seen. Me, a population scientist, understanding ion channels? That is amazing. One of my professors once said, “All drugs are poisons…but some have good side-effects”. This book is great on dosing, side-effect profiles, drug interactions, and how to use the agents in care. The enlightened authors delicately weave in the results of important clinical trials, meta-analyses, and key guideline recommendations too. Each chapter finishes with a concise summary.
Most importantly, the section editors don’t just opine on how one might go about treating cardiovascular conditions with drugs, they tell you how to do it. Those of us who take care of patients like to know how experts do it. Opie and Gersh, and their troupe of contributors, are all experts. They talk from both science and experience. The book is useful. I now must confess that most of my medical referencing is done online. Big fat textbooks are in the library, not on my desk or in our clinic area. But Drugs for the Heart is a rare exception. It has been a staple for my on-the-job learning for many years. This new edition is even better than the last, and that one was good. I use it, and I recommend it to you—and for the young learners, the book opens best with the binding on your left.
Kim Eagle [email protected]
www.thelancet.com Vol 374 August 15, 2009
For the Jupiter trial see N Engl J Med 2008; 359: 2195–2207 DOI:10.1056/ NEJMoa0807646
Thanks to the greater efficacy of the statins it was now possible to show in controlled clinical trials that these drugs were equally effective in men and in women; in the old and in the young, in people with diabetes and in the non-diabetic. Larger doses were used to reduce LDL cholesterol concentrations to unprecedented new lows—for example, last year’s JUPITER study of rosuvastatin reported that mean LDL concentrations fell by almost 50% in the treatment group and hard primary endpoints were reduced by 44%. The statins have already earned their place alongside quinine, aspirin, and penicillin as drugs that revolutionised medicine. Preventive cardiology now competes successfully with cardiac catheterisation and revascularisation. In Triumph of the Heart, Li, who was a key player in the group at Parke-Davis
that developed atorvastatin (Lipitor), focuses on the ways in which the pharmaceutical industry responded to Endo’s discovery. Roger Newton headed the team and Li was the medicinal chemist. His book offers valuable insights into the way a drug company goes about building a platform for a potential “blockbuster”. Although Lipitor was the fifth statin to reach market, it quickly jumped into first place. Annual sales ultimately topped US$12 billion per year in 2007, making it the best-selling drug in history. Have we gone as far as we can go? I think not. The reduction in fatal and non-fatal infarction in statin trials to date has averaged 30–35% and that is quite remarkable. However, I think the results of these trials underestimate the ultimate potential of the statins. First of all, the trials have mostly run the canonical 5 years; results of longer-
term treatment may well be even more impressive. Second, almost all the studies have used monotherapy; we know we can lower LDL concentrations more effectively with combined drug treatment and we know that the results support the position of those who say “the lower the better”. Finally, the trials to date have dealt mostly with people aged 60 years and older— ie, people who already have advanced arterial lesions—predictably results will be more impressive if we intervene earlier, when the lesions are less advanced and possibly more readily reversible. The story of the statins is not over; the best is yet to come.
Daniel Steinberg [email protected] DS is the author of The Cholesterol Wars: the Skeptics vs the Preponderance of Evidence (Academic Press/Elsevier, 2007).
In brief Book Drugs for the heart
Drugs for the Heart, 7th Edition Expert Consult: Online and Print Lionel H Opie, Bernard J Gersh. Saunders/Elsevier, 2009. Pp 512. US$64·95. ISBN 978-1-4160-6158-8.
The Lancet is published by Elsevier Ltd.
518
I feel like a dinosaur. I’m surrounded by electronic blather. My hometown newspaper is going online, which to me means away. The paper journal that I used to edit is now electronic. The residents and medical students that I teach are “connected” all the time. Several of them don’t even own a textbook. Are there any books left? Well, are there? The answer is a resounding yes. I got my Drugs for the Heart, 7th Edition, by Lionel Opie and Bernard Gersh, the other day and smiled all the way home. I am not yet extinct after all. Oh, I know that the book is also available online—no doubt my residents and students will be delighted with that version—but I like the paper version. Packed with useful information, this book is smaller than my laptop, mercifully bigger than my Blackberry, and infinitely navigable in 12 lucid and
straightforward chapters. Everything you need to know about drugs for the heart is here: β blockers; nitrates; calcium channel blocking drugs; diuretics; inhibitors of the renin-angiotensin system; drugs for heart failure; antihypertensives; antiarrhythmics; antithrombotics; drugs for lipids, metabolic syndromes, and diabetes; and when to use each drug. The book has the clearest figures and tables that I have ever seen. Me, a population scientist, understanding ion channels? That is amazing. One of my professors once said, “All drugs are poisons…but some have good side-effects”. This book is great on dosing, side-effect profiles, drug interactions, and how to use the agents in care. The enlightened authors delicately weave in the results of important clinical trials, meta-analyses, and key guideline recommendations too. Each chapter finishes with a concise summary.
Most importantly, the section editors don’t just opine on how one might go about treating cardiovascular conditions with drugs, they tell you how to do it. Those of us who take care of patients like to know how experts do it. Opie and Gersh, and their troupe of contributors, are all experts. They talk from both science and experience. The book is useful. I now must confess that most of my medical referencing is done online. Big fat textbooks are in the library, not on my desk or in our clinic area. But Drugs for the Heart is a rare exception. It has been a staple for my on-the-job learning for many years. This new edition is even better than the last, and that one was good. I use it, and I recommend it to you—and for the young learners, the book opens best with the binding on your left.
Kim Eagle [email protected]
www.thelancet.com Vol 374 August 15, 2009