Factors associated with the discontinuation of evidence-based cardiovascular therapies in patients with stable coronary artery disease: a primary care perspective.

BACKGROUND: To identify factors associated with the discontinuation of evidence-based cardiovascular therapies after hospital discharge for a coronary event. DESIGN: Cross-sectional study carried out between June and October 2004 in 1799 primary care centers throughout Spain. PATIENTS AND METHODS: Eight thousand eight hundred and seventeen patients (73.7% males; 65.4 years) admitted for coronary disease causes in the past 6 months to 10 years and attending primary care postdischarge from hospital. Current medications, those prescribed at hospital discharge, and the development of adverse events, new risk factors, and comorbidities during follow-up, were collected from clinical records. RESULTS: After a median follow-up of 37.4 months, discontinuation rate of lipid-lowering agents, angiotensin renin system blockers, antiplatelet drugs, and beta-blockers were 7.2, 9.1, 10, and 20%, respectively. Of these, 10.8, 16.5, 9.9, and 20.1%, respectively, were because of adverse events. Factors associated with the discontinuation of lipid-lowering agents were the development of hypertension and diabetes during the follow-up. Discontinuation of antiplatelet drug was associated with an earlier history, or with de-novo occurrence, of atrial fibrillation. Discontinuation of angiotensin renin system blockers was associated with the development of atrial fibrillation, diabetes and hypercholesterolemia, and discontinuation of beta-blockers with de-novo appearance of peripheral artery disease, cerebrovascular disease, and heart failure. CONCLUSION: In patients followed-up in primary care, the discontinuation rate of cardiovascular disease medications was low and was mainly related to the development of adverse events together with new risk factors and comorbidities arising after hospital discharge.

Patients at high risk of cerebrovascular disease: the REACH study.

Cerebrovascular disease is one of the leading causes of morbidity and mortality in developed countries. The identification of at-risk individuals is a high priority so that efficacious preventive measures can be implemented. Subjects with the highest risk of cerebrovascular diseases are those who already have had a stroke or a transient ischemic attack, and those with vascular disease in other territories, either in coronary or peripheral arteries. Other subjects at risk are those with cardiac disease, such as atrial fibrillation, those with hypertension, diabetes and smoking habit, as well as individuals with subclinical vascular disease. Although there is considerable evidence for the efficacy of preventive treatment in this population, the percentage of patients receiving optimum treatment is far from ideal. There is a need to implement strategies in the population directed towards increasing awareness of the need to establish healthy habits and adequate preventive pharmacological treatment that could reduce the incidence of this debilitating disease.

Achievement of therapeutic goals and utilization of evidence-based cardiovascular therapies in coronary heart disease patients with chronic kidney disease.

To evaluate whether the presence of chronic kidney disease (CKD) influenced the rate of prescription of evidence-based cardiovascular preventive therapies and attainment of therapeutic goals in patients with stable coronary heart disease, 7,884 patients (mean age 65.4 years; 81.7% men; 22.4% with CKD) attended to in 1,799 primary-care centers and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years were recruited. Glomerular filtration rate (GFR) was estimated using the MDRD Study equation. Results indicated that patients with CKD received more diuretics (47.6% vs 32.8%; p = 0.034), calcium channel blockers (29.3% vs 23.2%, p = 0.027); and blockers of the angiotensin-renin system (76.4% vs 65.3%; p <0.001). The lower prescription rate of antiaggregants, beta blockers, and statins in subjects with CKD did not reach statistical significance in multivariate analysis. A lower percentage of subjects with CKD achieved good control of blood pressure (39.2% vs 65.4%; p <0.001) and glycosylated hemoglobin (43.9% vs 53.4%; p <0.001) relative to patients without CKD. Only 11.8% of patients with CKD had optimum control of all risk factors. Using multivariate analysis, the presence of CKD was inversely related to the degree of risk-factor control, especially in groups with low GFR. In conclusion, patients with stable coronary heart disease and CKD attended to in primary-care centers had poorer control of coronary heart disease risk factors than those with normal GFR despite receiving a similar rate of prescription of evidence-based cardiovascular disease preventive therapies.

[Occult chronic kidney disease in patients with stable coronary heart disease]. / Insuficiencia renal crónica oculta en pacientes con enfermedad coronaria estable.

BACKGROUND AND OBJECTIVE: Chronic kidney disease (CKD) increases cardiovascular risk mainly in subjects with coronary heart disease. The aim of this study was to evaluate the prevalence of occult CKD (OCKD) in stable coronary heart disease patients and to study the factors associated in order to improve its detection. PATIENTS AND METHOD: Cross sectional study of 7,884 patients who had had a coronary event requiring hospitalization in the previous 6 months to 10 years. Glomerular filtration rate was estimated by means of the Modification of Diet in Renal Disease (MDRD) study equation. CKD was defined as a glomerular filtration rate lower than 60 ml/min/1.73 m(2), and OCKD when, in addition, serum creatinine was < 133 mmol/l in men and < 124 mmol/l in women. RESULTS: The mean age was 65.3 years, 73.7% male and 22.4% had CKD, 68.3% of them with normal serum creatinine. In subjects with OCKD the prevalence of risk factors and cardiovascular diseases associated was intermediate between subjects without CKD and subjects with CKD and high serum creatinine. Age, female sex, hypertension, diabetes, heart failure, cerebrovascular disease and peripheral artery disease were significantly and independently associated with OCKD in the multivariate analysis. CONCLUSIONS: Almost one in 4 subjects with stable coronary heart disease had CKD, most of them with normal serum creatinine, mainly women and older patients.

Gender differences in evidence-based pharmacological therapy for patients with stable coronary heart disease.

BACKGROUND: Women have a higher morbidity and mortality than men after an acute coronary event. We analyzed the prescription rates of evidence-based pharmacological therapies for patients with stable coronary heart disease and whether there were any differences with respect to gender. DESIGN: This cross-sectional study evaluated 8817 patients, 26.3% women, receiving attention from 1799 family doctors in primary care centers (PCC) throughout Spain, and who had had a coronary event requiring hospitalization in the previous 6 months to 10 years. RESULTS: Mean age was 65.4 years and a mean time-lapse since hospitalization of 37.4 months. In the overall population, prescription medications were: antiplatelet drugs in 80.5% of patients, 79% statins, 66% blockers of the angiotensin-renin system (BARS) and 47% beta-blockers. Males received less cardiovascular disease medications than females (4.3+/-1.5 versus 4.6+/-1.6, respectively; p<0.001), but when adjusted for risk factors the significance was lost (p=0.231). Following adjustment for risk factors and for co-morbidities, the use of diuretics was significantly higher in women while beta-blockers and statins were higher in men. The triple combination of antithrombotics, beta-blockers and statins was used in 41.4% (43.8% males versus 34.6% females; p<0.001) while 24.3% used this triple combination plus a BARS; without significant difference between the genders. CONCLUSIONS: An important percentage of patients with stable coronary disease, particularly women, attended-to in primary care do not receive medications that have been shown to decrease the morbido-mortality of cardiovascular disease.

Insuficiencia renal crónica oculta en pacientes con enfermedad coronaria estable / Occult chronic kidney disease in patients with stable coronary heart disease

FUNDAMENTO Y OBJETIVO: La presencia de insuficiencia renal crónica (IRC) aumenta el riesgo de enfermedadcardiovascular, especialmente en los pacientes con enfermedad coronaria. El objetivode este estudio ha sido examinar la prevalencia de IRC oculta (IRCO) en pacientes con enfermedadcoronaria estable e investigar los factores asociados a ella para favorecer su detección.PACIENTES Y MÉTODO: Se ha realizado un estudio transversal en el que participaron 7.884 sujetosque habían ingresado por un episodio coronario entre 6 meses y 10 años antes. Se calculó elfiltrado glomerular según la ecuación abreviada del estudio Modification of Diet in Renal Disease(MDRD). Se consideró IRC cuando el filtrado glomerular era menor de 60 ml/min/1,73 m2 eIRCO cuando además la creatinina sérica era inferior a 133 mmol/l en varones y a 124 mmol/len mujeres.RESULTADOS: La edad media de la población estudiada era 65,3 años y el 73,7% eran varones.Presentaba IRC un 22,4%, de los que el 68,3% tenía cifras de creatinina normales. En los pacientescon IRCO la prevalencia de factores de riesgo y enfermedades cardiovasculares asociadasera intermedia entre aquellos sin IRC y entre los que presentaban IRC con creatinina elevada.La edad, el sexo femenino, la presencia de hipertensión arterial, diabetes, insuficienciacardíaca, enfermedad cerebrovascular y enfermedad arterial periférica se asociaron de manerasignificativa e independiente con la presencia de IRCO en el análisis multivariante.CONCLUSIONES: Casi uno de cada 4 pacientes con enfermedad coronaria estable presenta IRC, lamayoría de ellos con creatinina normal, siendo especialmente frecuente en las mujeres y con elaumento de la edad

BACKGROUND AND OBJETIVE: Chronic kidney disease (CKD) increases cardiovascular risk mainly insubjects with coronary heart disease. The aim of this study was to evaluate the prevalence ofoccult CKD (OCKD) in stable coronary heart disease patients and to study the factors associatedin order to improve its detection.PATIENTS AND METHOD: Cross sectional study of 7,884 patients who had had a coronary event requiringhospitalization in the previous 6 months to 10 years. Glomerular filtration rate was estimatedby means of the Modification of Diet in Renal Disease (MDRD) study equation. CKD wasdefined as a glomerular filtration rate lower than 60 ml/min/1.73 m2, and OCKD when, in addition,serum creatinine was < 133 mmol/l in men and < 124 mmol/l in women.RESULTS: The mean age was 65.3 years, 73.7% male and 22.4% had CKD, 68.3% of them withnormal serum creatinine. In subjects with OCKD the prevalence of risk factors and cardiovasculardiseases associated was intermediate between subjects without CKD and subjects with CKDand high serum creatinine. Age, female sex, hypertension, diabetes, heart failure, cerebrovasculardisease and peripheral artery disease were significantly and independently associatedwith OCKD in the multivariate analysis.CONCLUSIONS: Almost one in 4 subjects with stable coronary heart disease had CKD, most ofthem with normal serum creatinine, mainly women and older patients