Secondary prevention in coronary artery disease. Achieved goals and possibilities for improvements

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Abstract

Aim

To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronary artery disease at a university clinic.

Methods

The presence of risk indicators, including tobacco use, lipid levels, blood pressure and glucometabolic status, including 24-hour blood pressure monitoring and an oral glucose-tolerance test, was analysed.

Results

Of 1465 patients who were screened, 402 took part in the survey (50% previous myocardial infarction and 50% angina pectoris). Mean age was 64 years (range 40–85 years) and 23% were women. Present medications were: lipid lowering drugs (statins; 94%), beta-blockers (85%), aspirin or warfarin (100%) and ACE-inhibitors or angiotensin II blockers (66%).

Values above target levels recommended in guidelines were: a) low density lipoprotein (LDL) in 40%; b) mean blood pressure (day or night) in 38% and c) smoking in 13%. Of all patients, 66% had at least one risk factor (LDL or blood pressure above target levels or current smoking).

An abnormal glucose-tolerance test was found in 59% of patients without known diabetes. If no history of diabetes, 85% had either LDL or blood pressure above target levels, current smoking or an abnormal glucose-tolerance test. However, with treatment intensification to patients with elevated risk factors 56% reached target levels for blood pressure and 79% reached target levels for LDL.

Conclusion

Six months after hospitalisation due to coronary artery disease, despite the high use of medication aimed at prophylaxis against recurrence, the majority were either above target levels for LDL or blood pressure or continued to smoke.

Introduction

Coronary heart disease (CHD) is the primary cause of death in the developed countries. Despite an improved prognosis probably due to decline in certain risk factors, early revascularisation and improved drug therapy, the burden still remains high. Most probably this is due to an ageing population. Patients with known coronary heart disease run the highest risk of subsequent events, with around 20% running a 10-year risk [1]. These patients with prior disease should be amongst the top priority for prevention. Risk reduction in those patients with known CHD is referred to as secondary prevention.

The INTERHEART study [2] is a large, international, standardised case-control study, designed to assess the importance of risk factors for coronary artery disease. A very high percentage (90% for men, 94% for women) of population-attributable risk in this study was accounted for by easily measured and potentially modifiable risk factors. The most important risk factors identified in the study were high lipid levels (OR 3.2), smoking (OR 2.9), diabetes (OR 2.4) and hypertension (OR 1.9).

Secondary prevention measures are effective in reducing coronary mortality and morbidity [3]. They include lifestyle changes (dietary modification, smoking cessation and weight reduction) and prophylactic drug therapy (beta-blockers, ACE inhibitors, anti-platelet agents and lipid lowering therapy) [4]. Secondary prevention measures have been performed and showed that a large percentage of patients with coronary artery disease do not reach target levels [5].

Prophylactic drug therapy, for example, is underused, despite the fact that the medications are well tolerated and current published guidelines are available [6]. Failure to achieve treatment goals has been related to poor patient risk factor recognition [7] and non-compliance [8], physician non-adherence and co-morbidity resulting in therapy modification.

The primary objective was to describe the secondary prevention measures at a university clinic in Gothenburg, Sweden, for a population with unstable and stable coronary artery disease. A secondary objective was to describe the possibilities to improve some of these measures.

Section snippets

Target population

Patients who were hospitalised at Sahlgrenska University Hospital/Sahlgrenska with a main diagnosis of coronary artery disease (i.e. myocardial infarction or angina pectoris) during the time period 1 Oct 2007–1 Oct 2009. Sahlgrenska has a catchment area of 250 thousand inhabitants.

Coronary artery disease was diagnosed with coronary angiography either prior to or at the time of hospitalisation.

Inclusion criteria

All patients who fulfilled the criteria stated above.

Exclusion criteria (Table 1)

  • 1)

    High age in combination with severe co-morbidity

Results

In all, 1465 patients were screened for evaluation (i.e. were hospitalised for coronary artery disease during the time of the survey).

Among these patients, 402 (27%) took part in the final evaluation. These patients were evaluated with regard to potential risk indicators. The reasons for exclusion are given in Table 1. The high proportion (38%) excluded due to delayed evaluation was caused by the lack of organisational capacity within the hospital to call all patients within 6 months after

Risk factors

In this study, we have demonstrated a high prevalence of modifiable risk factors in patients with known coronary artery disease. The study is unique since we analysed blood pressure and heart rate over 24 h and related our findings to office blood pressure. We also validated smoking habits with biochemical markers. Finally we evaluated the possibility to quickly treat blood pressure, lipid levels and heart rate in order to reach target levels.

In a large European Survey (EUROASPIRE III) [12] from

Possibility to normalize elevated blood pressure, lipids and heart rate

Our data suggest that it is possible to normalize 80% of patients with elevated lipids and more than 50% of patients with blood pressure or heart rate elevation with treatment modification.

Conclusions

Secondary prevention is important in order to fight the further progression of atherosclerotic disease and reduce mortality in coronary artery disease. The majority of patients do not achieve the guideline target goals and further intensification of therapy is indicated in order to reach them.

In many regards the results from this study is similar to larger multicenter studies (as the EUROASPIRE) but in this study the patients underwent additional evaluation tests such as ambulatory BP,

Conflict of interest

There are no conflicts of interest.

Acknowledgement

This study was supported by grants from Pfizer Pharmaceuticals. The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology. Shewan LG and Coats AJ. Ethical authorship and publishing. Int J Cardiol 2010;144: 1–2 [29].

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