• Clare H Luymes, Poortvliet Rosalinde K E RKE Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands., Nan van Geloven, de Waal Margot W M MWM Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands., Yvonne M Drewes, Jeanet W Blom, Nynke Smidt, Assendelft Willem J J WJJ Department of Primary and Community Care, Radboud University Medical Centre, PO Box 9101, 6500 HB, Nijmegen, The Netherlands., Wilbert B van den Hout, Wouter de Ruijter, and Mattijs E Numans.
• Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC, Leiden, The Netherlands. c.h.luymes@lumc.nl.
• Bmc Med. 2018 Jan 11; 16 (1): 5.

BackgroundThe use of cardiovascular medication for the primary prevention of cardiovascular disease (CVD) is potentially inappropriate when potential risks outweigh the potential benefits. It is unknown whether deprescribing preventive cardiovascular medication in patients without a strict indication for such medication is safe and cost-effective in general practice.MethodsIn this pragmatic cluster randomised controlled non-inferiority trial, we recruited 46 general practices in the Netherlands. Patients aged 40-70 years who were using antihypertensive and/or lipid-lowering drugs without CVD and with low risk of future CVD were followed for 2 years. The intervention was an attempt to deprescribe preventive cardiovascular medication. The primary outcome was the difference in the increase in predicted (10-year) CVD risk in the per-protocol (PP) population with a non-inferiority margin of 2.5 percentage points. An economic evaluation was performed in the intention-to-treat (ITT) population. We used multilevel (generalised) linear regression with multiple imputation of missing data.ResultsOf 1067 participants recruited between 7 November 2012 and 18 February 2014, 72% were female. Overall, their mean age was 55 years and their mean predicted CVD risk at baseline was 5%. Of 492 participants in the ITT intervention group, 319 (65%) quit the medication (PP intervention group); 135 (27%) of those participants were still not taking medication after 2 years. The predicted CVD risk increased by 2.0 percentage points in the PP intervention group compared to 1.9 percentage points in the usual care group. The difference of 0.1 (95% CI -0.3 to 0.6) fell within the non-inferiority margin. After 2 years, compared to the usual care group, for the PP intervention group, systolic blood pressure was 6 mmHg higher, diastolic blood pressure was 4 mmHg higher and total cholesterol and low-density lipoprotein-cholesterol levels were both 7 mg/dl higher (all P < 0.05). Cost and quality-adjusted life years did not differ between the groups.ConclusionsThe results of the ECSTATIC study show that an attempt to deprescribe preventive cardiovascular medication in low-CVD-risk patients is safe in the short term when blood pressure and cholesterol levels are monitored after stopping. An attempt to deprescribe medication can be considered, taking patient preferences into consideration.Trial RegistrationThis study was registered with Dutch trial register on 20 June 2012 ( NTR3493 ).

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