James
Ask a cardiologist privately and most will admit to something they rarely say out loud in clinic: a good number of their patients are not taking every tablet on the chart. Someone skips the water tablet on a day they need to leave the house. Someone else quietly stops the statin after reading something alarming online. A second blood pressure tablet gets missed so often it stops being an accident and becomes a pattern, and nobody mentions it at the next check-up.
For a long time, the standard response was to repeat the instructions and hope adherence improved. That is starting to change. A small but growing number of cardiology teams are now doing something closer to what many patients have already been doing quietly on their own, only with proper oversight: asking, drug by drug, whether everything on a long prescription list is still doing enough good to justify the risk of keeping it there.
Why the list grows in the first place
Heart disease treatment has improved largely through addition. Someone recovering from a heart attack might reasonably leave hospital on an antiplatelet, a statin, a beta blocker, an ACE inhibitor or ARB, and occasionally a fifth drug to manage fluid or rhythm. Most of the types of heart medication prescribed after a cardiac event earn their place through a dedicated randomised trial, usually run in people younger and less complicated than the person actually swallowing the pill years later.
What gets tested far less often is how five or six of these drugs behave together in someone in their eighties, with reduced kidney function, two or three unrelated conditions competing for attention, and a daily routine that does not always run to a fixed schedule of doses and meals. Guidelines are written condition by condition. Patients live with all of their conditions at once, and the arithmetic of combining several individually evidence-based treatments does not always add up to a better outcome for that particular person.
What the evidence on removing a drug actually shows
The scale of the problem is easiest to see in heart failure, where prescribing has been tracked closely over time. An analysis of Medicare patients hospitalised for heart failure found that the share discharged on ten or more medications rose from 41% in the mid-2000s to 68% a decade later, and that most of those medications were not for heart failure, or any heart condition, at all (NHLBI, 2020).
Noticing there are too many drugs on a list is one thing. Removing one safely is a different question entirely, and this is where the evidence has genuinely moved in the past few years. The OPTIMISE trial, run across dozens of primary care sites in England, enrolled 569 patients aged 80 and over with well-controlled blood pressure on at least two antihypertensives, and randomly assigned half of them to have one drug withdrawn. After 12 weeks, blood pressure remained under control in 86.4% of the group that had a drug removed, against 87.7% of those left on their usual regimen, close enough to meet the trial’s own definition of non-inferiority (JAMA, 2020).
The result was not unambiguous. The group that had a medication withdrawn reported more adverse events overall, and roughly a third of them were back on the drug within 12 weeks after their blood pressure crept up again. Adverse events serious enough to need hospital treatment, though, were not significantly more common in either group. Read together, the trial and the commentary that followed it point to the same conclusion: careful deprescribing can work for the right patient, but it is not something to attempt without a doctor watching closely afterwards.
Deprescribing is not the same as quietly stopping your own medication
This distinction matters more than it might first appear. A patient who stops a blood thinner because of bruising, without telling anyone, is taking on a real and sometimes serious risk, particularly soon after a stent or an episode of atrial fibrillation. Someone whose statin is reviewed and formally withdrawn by their cardiologist, because their remaining life expectancy is shorter than the years it typically takes a statin to show measurable benefit, is a different decision entirely, made with the relevant numbers in front of both doctor and patient.
A widely cited review in the Journal of the American College of Cardiology makes a related point: cardiovascular drugs tend to accumulate because each one has been proven to help in its own trial, but very few trials test what happens once several are combined in an older person managing more than one condition at a time (JACC, 2019). The review argues for treating medication review as an active, ongoing part of cardiology care, rather than something reserved for patients who are already visibly struggling.
What an actual review conversation involves
In practice, a structured medication review tends to ask a narrower question than “can we cut the list”, closer to: would this particular drug still be started today, at this dose, given everything now known about this patient. Some cardiovascular prescriptions exist only to manage a problem caused by an earlier one, a diuretic added years ago to deal with ankle swelling from a calcium channel blocker, for example, and reviewing the original cause can sometimes remove two medications rather than one.
Increasingly, this work does not fall to the cardiologist alone. Larger cardiology services are involving pharmacists directly in the review, checking not just the prescribed list but anything bought without one, since fish oil, certain cold remedies and even some herbal supplements can interact with blood thinners or blood pressure medication in ways a short consultation rarely has time to unpick.
Time to benefit is another factor that rarely comes up in a rushed appointment but matters considerably. A statin might take several years of consistent use before its risk reduction becomes measurable. For a patient with a shorter remaining life expectancy from an unrelated condition, that trade-off looks very different from the one it presented at 55. None of this is an argument for abandoning preventive medication as a rule. It is an argument for revisiting the reasoning behind it as circumstances change, rather than assuming the original decision still applies indefinitely.
The direction of travel in cardiology is not towards fewer drugs for their own sake. It is towards prescriptions that are reviewed with the same rigour they were written with in the first place. For patients managing a long list of heart medication, the more useful question at the next appointment may not be whether to keep taking everything as prescribed, which usually remains the safest default, but whether each item on that list has actually been looked at recently, and why it is still there.
