Failure to achieve recommended LDL cholesterol levels by suboptimal statin therapy relates to elevated cardiac event rates.

OBJECTIVES: The majority of patients with myocardial infarction (MI) and hypercholesterolaemia does not achieve guideline recommended low-density lipoprotein cholesterol (LDL) levels. Suboptimal dosages of statins explain this dilemma in most patients. DESIGN AND SETTING: We evaluated the relationship between statin treatment quality (optimal: LDL<115 mg/dl, suboptimal: LDL>/=115 mg/dl, no statin therapy despite hypercholesterolaemia) and the subsequent incidence of coronary events (coronary death, nonfatal MI, bypass surgery) over a 30 months follow-up in a large cohort of post MI patients with hypercholesterolaemia (n=2045). Analysis was performed in a nested case-control manner comparing 173 cases with a coronary event and 346 matched controls. RESULTS: Patients who developed a coronary event were treated optimally in 11.0%, suboptimally in 43.4% (p<0.05 vs. optimal treatment) and were untreated in 45.7% (p<0.001 vs. optimal treatment). Respective numbers in event-free patients were 21.4%, 47.7%, and 30.9%. After adjustment for most potential confounders, including all cardiovascular risk factors and medication, the relative risk of future non-fatal MI and coronary death associated with a suboptimal statin treatment was 2.02 (95% CI 1.04 to 4.18) compared to optimal statin treatment. Moreover, the statin equivalent dose in optimally treated individuals was significantly higher than in suboptimally treated individuals (0.85+/-0.03 vs. 0.78+/-0.02, p<0.05). CONCLUSION: In this community-based study, a lipid lowering therapy with statins into the recommended target range of LDL levels may be associated with decreased cardiovascular risk compared to a statin therapy without titrating the LDL level below 115 mg/dl. Thus, the quality of statin treatment was identified as an independent predictor of coronary events in post MI patients.

[Inpatient rehabilitation improves implementation of therapeutic guidelines for secondary prevention in patients with coronary heart disease]. / Die stationäre Rehabilitation verbessert die Umsetzung der Therapierichtlinien zur Sekundärprävention bei Patienten mit koronarer Herzerkrankung.

In Germany, measures for secondary prevention in patients with coronary artery disease are poorly utilized. We therefore investigated whether a cardiac in-hospital rehabilitation and education program may enhance the implementation of respective guidelines in patients with severe coronary artery disease (CAD). Specifically, we developed a case-control design in siblings with severe CAD in order to achieve optimal matching for patients with or without participation in the rehabilitation program. By the screening of more than 200,000 patient charts in 15 cardiac rehabilitation clinics, we identified 1500 families in which at least two siblings suffered from severe coronary artery disease. In 268 such sibling pairs, siblings were discordant with respect to participation in a 3-4 week cardiac in-hospital rehabilitation program. The coronary risk profile was studied, first, retrospectively at the time of hospitalization for acute MI or revascularization procedures and, secondly, prospectively at the time of follow-up (on average 5.2 years later). At the time of the acute cardiac event, both groups showed an equal risk factor distribution suggesting appropriate matching. However, at follow-up the number of individuals taking antihypertensive medication and displaying effective antihypertensive treatment (< or = 140/90 mmHg) was significantly higher in the rehabilitation group (92.2 vs. 82.1%, p < 0.01; 59.7 vs. 37.2%). Accordingly, rehabilitation siblings presented with significantly lower systolic (137 +/- 1 vs. 145 +/- 1 mmHg; p < 0.01) and diastolic blood pressure (82 +/- 1 vs. 85 +/- 1 mmHg; p < 0.01). The utilization of CSE inhibitors was also significantly higher in siblings participating in the rehabilitation program (57.5 vs. 43.1%; p < 0.01), leading to significantly lower blood lipid levels in these siblings (total cholesterol 225 +/- 3 vs. 236 +/- 3 mg/dL, p < 0.01; LDL cholesterol 148 +/- 3 vs. 158 +/- 3 mg/dL, p < 0.01). Moreover, participation in the cardiac rehabilitation stimulated markedly more smokers to quit (80.8 vs. 57.6%, p < 0.01). Additionally, there was a strong temporal trend from 1997 until 2000 towards improved control of arterial hypertension in rehabilitation siblings. In parallel, the utilization of CSE inhibitors increased over time and LDL cholesterol decreased. These favorable temporal trends were also observed in siblings not participating in the rehabilitation program, however, to a lesser extent. Taken together, in the last four years, the implementation of secondary preventive strategies in patients with cardiac disease improved. Siblings who participated in a rehabilitation program displayed a better control of cardiovascular risk factors as compared to those not participating in such a program. Thus, an in-hospital cardiac rehabilitation program may successfully encourage the implementation of measures for secondary prevention and enhance the treatment of coronary risk factors.