Secondary prevention for coronary artery disease

Building a Footbridge From Research to Practice in Cardiovascular Risk Reduction

As Rippe, Angelopoulos, and Zukley noted in their State-of-the-Art Review, empirically supported lifestyle modification strategies offer numerous advantages over other modalities for reducing cardiovascular risks. Yet, despite compelling evidence for their implementation, the translation of lifestyle interventions from research to practice has been challenging. Their review prompts discussion of several especially thorny barriers including the persistent tensions between (1) research and practice, (2) main effects and mediators, (3) single and multifactor approaches to risk management, and (4) primary care and communitybased systems of health delivery.

Comparison of in-hospital secondary prevention for different vascular diseases

BACKGROUND

Secondary prevention of coronary artery disease is highly effective and implemented on a large scale. However, studies testing adherence to recommended secondary prevention of other vascular diseases are rare. Our goal was to evaluate whether the kind of vascular disease influences prescription practice of secondary drug prophylaxis at hospital discharge and to which extent secondary prevention is actually complete.

METHODS

A 3-month prospective observational review of the hospital discharge information of all patients hospitalized because of a vascular disease diagnosis: coronary artery disease (i.e. acute myocardial infarction [AMI] and chronic stable angina [CSA]); peripheral artery disease [PAD] and cerebrovascular disease [CVD]. The analysis was done by board registered internists with a structured form that founded on internationally accepted recommendations.

RESULTS

From 271 patients 191 had coronary artery disease (105 AMI and 86 CSA), 88 PAD and 72 CVD. Global prescription rate (mean; 95% CI) of indicated secondary prophylaxis drugs was 74.1% (69.9-78.2) for AMI, 72.4% (67.2-77.5) for CSA, 74.7% (68.8-80.7) for PAD and 72.1% (66.9-77.3) for CVD. The proportion of patients who were prescribed a complete bundle of recommended medications was globally 29.5% (24.1-35.0).

CONCLUSIONS

We found similar global prescription rates of secondary prevention for the different vascular diseases. However, only one third of the studied collective gets a complete set of required prophylactic drugs.

Cardiovascular risks of nonsteroidal antiinflammatory drugs in patients after hospitalization for serious coronary heart disease

BACKGROUND

The cardiovascular safety of individual nonsteroidal antiinflammatory drugs (NSAIDs) is highly controversial, particularly in persons with serious coronary heart disease.

METHODS AND RESULTS

We conducted a multisite retrospective cohort study of commonly used individual NSAIDs in Tennessee Medicaid, Saskatchewan Health, and United Kingdom General Practice Research databases. The cohort included 48566 patients recently hospitalized for myocardial infarction, revascularization, or unstable angina pectoris with more than 111000 person-years of follow-up. Naproxen users had the lowest adjusted rates of serious coronary heart disease (myocardial infarction, coronary heart disease death) and serious cardiovascular disease (myocardial infarction, stroke)/death from any cause, with respective incidence rate ratios (relative to NSAID nonusers) of 0.88 (95% CI, 0.66 to 1.17) and 0.91 (0.78 to 1.06). Risk did not increase with doses >or=1000 mg. Relative to NSAID nonusers, serious coronary heart disease risk increased with short term (<90 days) use for ibuprofen (1.67 [1.09 to 2.57]), diclofenac (1.86 [1.18 to 2.92]), celecoxib (1.37 [0.96 to 1.94]), and rofecoxib (1.46 [1.03 to 2.07]), but not for naproxen (0.88 [0.50 to 1.55]). Relative to naproxen, current users of diclofenac had increased risk of serious coronary heart disease (1.44 [0.96 to 2.15], P=0.076) and serious cardiovascular disease/death (1.52 [1.22 to 1.89], P=0.0002), and those of ibuprofen had increased risk of the latter end point (1.25 [1.02 to 1.53], P=0.032). Compared to naproxen in doses >or=1000 mg, serious coronary heart disease incidence rate ratios were increased for rofecoxib >25 mg (2.29 [1.24 to 4.22], P=0.008) and celecoxib >200 mg (1.61 [1.01 to 2.57], P=0.046).

CONCLUSIONS

In patients recently hospitalized for serious coronary heart disease, naproxen had better cardiovascular safety than did diclofenac, ibuprofen, and higher doses of celecoxib and rofecoxib.

[Control of coronary risk factors in secondary prevention: PRESENAP study]

BACKGROUND AND OBJECTIVE

Evaluate the overall achievement of goals in the control of risk factors in secondary prevention in patients who have suffered a coronary event and are followed up in primary care centers.

PATIENTS AND METHOD

Descriptive, transversal, multicenter study with sampling by consecutive inclusion of the first 5 patients attending the doctor's office who had suffered a coronary event 6 months to 10 years previously. The targets for control were: blood pressure < 140/90 mmHg in the general population and < 130/85 mmHg in diabetics; LDL-cholesterol < 100 mg/dl and no smoking habit.

RESULTS

8,817 patients (73.7% males) were included, with a mean (SD) age of 65.4 (10.3) years; 76.6% were hypertensive, 73.4% dyslipidemic and 32.7% diabetics; 60.2% achieved target blood pressure; 26.3% achieved LDL-cholesterol <100 mg/dl and 11.4% continued smoking; 16.4% fulfilled all recommendations. Factors independently related with good control were a lower age, male sex, patients who had been admitted with acute coronary syndrome without ST elevation (OR = 1.39; CI 95%, 1.01-1.93; p = 0.04) or for revascularization (OR = 1.37; CI 95%; 1.12-1.67; p = 0.002), patients with peripheral arterial disease (OR = 1.43; CI 95%, 1.11-1.84; p = 0.005) and when the physicians proposed suitable objectives (OR = 1.90; CI 95%, 1.48-2.44; p < 0.0001). Control was poorer in hypertensive or dyslipidemic patients.

CONCLUSIONS

Overall control of risk factors in secondary prevention of coronary disease is achieved in one in six patients attending primary care.