Article Text

Download PDFPDF
  1. Morris J Brown
  1. Correspondence to:
    Professor Morris Brown, Clinical Pharmacology Unit, Level 6, ACCI, Addenbrookes Hospital, Box 110, Cambridge CB2 2QQ, UK;

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Much of medicine is concerned with choosing the right treatment, and cardiologists have done well in recent years to ensure the choice is supported by good evidence. However, the greatest choice often starts where the evidence finishes—namely between drugs of the same class. This article seeks therefore to offer the principles which govern when and how it is appropriate to differentiate drugs within a class, and discuss topical examples among the drugs commonly used in cardiology.


The parameters which can reasonably be compared between drugs are shown in table 1. If this were all, it might be possible to devise semi-automatic algorithms to calculate which drug(s) have the highest score for any given indication. However, the relatively factual answers that could be filled in each cell of the table for a given drug are only part of the decision making process, and more judgemental are: (1) the strength of evidence for each of the answers; and (2) the second order issues of how to compare, for example, one drug of apparently superior efficacy with another which is better tolerated. Compliance is sometimes cited as a reason for choosing one drug rather than another; compliance is not itself a property of the drug, but a composite phenomenon reflecting the interplay between efficacy, tolerability, frequency or route of administration, and cost. Particularly contentious are questions of cost effectiveness. For example, the quality of the evidence for effectiveness may vary between drugs; or the cost of two drugs may be differentially influenced by factors like laboratory tests or number of visits, where savings can seem more virtual than real.

View this table:
Table 1

Parameters influencing rational choice among drugs

In this article I shall address some of the controversies regarding choice of drugs from commonly used classes in cardiology: angiotensin converting enzyme (ACE) inhibitors, statins, …

View Full Text

Linked Articles

  • Miscellanea
    BMJ Publishing Group Ltd and British Cardiovascular Society
  • Miscellanea
    BMJ Publishing Group Ltd and British Cardiovascular Society