Awesome read Dr. MW-S.  So, so true and I live in the world of industry.  The crying shame is the lack of patent enforcement that US companies are afforded abroad, which in my view results in the US population footing the bill for the rest of the world (as you stated in your article).

Maybe better primary prevention would help?  Question: how did this lady become dyslipidemic, hypertensive, diabetic and anginal in the first place?  Answer: through decades and decades of plaque accretion caused by poor habits in the context of poor genes.  Now you are seeing her in the last decade or two of her life - when health costs are known to soar - and because of positive RCT's, we have to pile on with lipitor, aspirin, plavix, coreg, altace, metformin, actos and now xarelto.  Note that all of these drugs have mortality benefit data so how do we pick and choose between them?  The RCT's don't help with that, so I do not see the latest trial as getting us thinking in the right direction, as you stated.

Even in the secondary prevention setting, do we need more antithrombotics in CAD/ACS? At what point are we going to take care of eliminating the nidus for future atherothrombotic events? Intensive risk factor control would do that. Getting lipids to unheard of very low levels, together with BP and blood glucose, physical activity, smoking cessation, diet, would pretty much eliminate the need for a third antithrombotic substance such as xarelto (just look at STENO-2).

But the other way to look at this is akin to antineoplastic therapy for cancer. No one questions the need for a cocktail of 3 or 4 or 5 toxic therapies for such a serious disease as cancer. Isn't CAD also a life-threatening disease? Isn't it also lifelong?

Just 3 perspectives from 1 person. 

Wow, finally! I'm a bit of an odd Pharmacist in that I've been saying for a long time that adding all these drugs is not the right answer. With compliance issues being what they are, would we be better off if we got 100 % compliance of an ASA a day. Rather than 30-50 % complience of a 2-3 drug regimen. Not to mention the increased quality of life with an extra $360 or more/month. The recent Free-MI trial pretty much proved that you can take a horse to water, give him the water, tell him how important water is and it doesn't matter 67% of the time.

I do understand though that physicians are compelled to try to treat all of these folks issues. They are also held liable if they do not. But that does not mean it's the best thing to do.

One way to analyze studies is to assess the overall outcomes of things that are in the "good" and "bad" column. The primary endpoint of having MI, stroke, or death plus fatal bleeding. I am sure everyone can agree that dying is a bad thing. There is too great a reliance upon RRR, HR, OR and NOT absolute differences for the "benefit" of a drug.  Adding the primary outcome plus the worst adverse effect gives a 1.7% absolute difference for 2.5 mg and 5 mg doses of rivaroxaban.  This can be compared to the 7-7.4% of patients NOT getting a thienopyridine and between 1.3-1.5% who did not get aspirin (as stated they did in the methods). Also, statins were not given to 16.1 to 16.4% of the patients. This is clearly below any standards of care. The authors should inform the readers if these differences mattered to the outcome.

One can also reverse the equation when assessing data and ask what % did not have an event (avoiding the primary enpoint PLUS fatal bleeding) and find those numbers of 2.5 mg, 5 mg, combination, and placebo were 90.8%, 90.8%, 90.8%, and 89.1%, respectively. The rate of fatal bleeding was higher in the 5 mg group than 2.5 mg and placebo. MANY patients would say these are not very different results.

Asking how much of a difference makes a difference is something I was taught a long time ago. I am not sure this is a huge difference, despite the p values! 

I am glad we have come a long way from chicken soup and bed rest. The compliance issue has been a bane for sometime now, but that is not the reason not to use medications which we think serve better, particulalry after ACS. Patient economics is an important consideration, but as a practioner it is difficult to shy away from prescribing medications we think works.... being a good doctor is certaainly more than writing prescriptions. 

I am not sure which new drug costs 360$ a month in the managment of angina, but it is difficult to understand why doctors write prescriptions without giving the patient heads up about how much it would cost and verify with them if they can afford it.... this piece serves as a good reminder to check with the patient every time we write a new precription if they can afford it or not.