Optimal Medical Therapy Goals for US Adults With CAD
Objectives. In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial.
Background. In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures.
Methods. The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m2; and 7) exercise ≥4 days per week.
Results. The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals.
Conclusions. There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD.
Coronary artery disease (CAD) is highly prevalent in the United States. The American Heart Association (AHA) estimates that 15,400,000 Americans have CAD and that CAD accounted for 1 in 6 deaths in the United States in 2009. The total estimated annual direct and indirect cost of CAD in the United States is $195.2 billion.
Current guideline recommendations for the management of patients with stable CAD involve intensive risk factor management and anti-ischemic therapies, with revascularization reserved for individuals whose symptoms persist or progress despite intensive medical therapy. Despite these recommendations, many patients undergo revascularization, often because of emotional or psychological factors on the part of both patients and physicians. More than 1 million percutaneous coronary interventions (PCIs) are performed annually in the United States. Although estimates vary, it appears that at least one-half of all PCIs in the United States are performed electively.
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial recently demonstrated that, compared with a strategy of PCI plus optimal medical therapy, an initial strategy of optimal medical therapy alone, with PCI reserved for those with refractory angina, had similar rates of death or nonfatal myocardial infarction in individuals with stable CAD who had undergone coronary angiography before randomization. Also, over a median follow-up of 4.6 years, only 33% of individuals randomized to the optimal medical therapy group required revascularization, suggesting that two-thirds of individuals with stable CAD could potentially avoid PCI during this time period if treated initially with optimal medical therapy alone.
Because clinical trial populations tend to be more adherent and health conscious, it is not clear to what extent individuals with stable CAD in the United States achieve the risk factor goals used in the COURAGE trial. Therefore, using data on participants who reported a history of CAD at baseline in the national REGARDS (REasons for Geographic and Racial Differences in Stroke) study, we sought to examine the proportion of individuals with risk factor levels similar to the goals used in the COURAGE trial. Additionally, we examined sociodemographic factors associated with being at these risk factor goals.
Abstract and Introduction
Abstract
Objectives. In a nonclinical trial setting, we sought to determine the proportion of individuals with coronary artery disease (CAD) with optimal risk factor levels based on the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation) trial.
Background. In the COURAGE trial, the addition of percutaneous coronary intervention (PCI) to optimal medical therapy did not reduce the risk of death or myocardial infarction in stable CAD patients but resulted in more revascularization procedures.
Methods. The REGARDS (REasons for Geographic And Racial Differences in Stroke) study is a national prospective cohort study of 30,239 African-American and white community-dwelling individuals older than 45 years of age who enrolled in 2003 through 2007. We calculated the proportion of 3,167 participants with self-reported CAD meeting 7 risk factor goals based on the COURAGE trial: 1) aspirin use; 2) systolic blood pressure <130 mm Hg and diastolic blood pressure <85 mm Hg (<80 mm Hg if diabetic); 3) low-density lipoprotein cholesterol <85 mg/dl, high-density lipoprotein cholesterol >40 mg/dl, and triglycerides <150 mg/dl; 4) fasting glucose <126 mg/dl; 5) nonsmoking status; 6) body mass index <25 kg/m2; and 7) exercise ≥4 days per week.
Results. The mean age of participants was 69 ± 9 years; 33% were African American and 35% were female. Overall, the median number of goals met was 4. Less than one-fourth met ≥5 of the 7 goals, and 16% met all 3 goals for aspirin, blood pressure, and low-density lipoprotein cholesterol. Older age, white race, higher income, more education, and higher physical functioning were independently associated with meeting more goals.
Conclusions. There is substantial room for improvement in risk factor reduction among U.S. individuals with CAD.
Introduction
Coronary artery disease (CAD) is highly prevalent in the United States. The American Heart Association (AHA) estimates that 15,400,000 Americans have CAD and that CAD accounted for 1 in 6 deaths in the United States in 2009. The total estimated annual direct and indirect cost of CAD in the United States is $195.2 billion.
Current guideline recommendations for the management of patients with stable CAD involve intensive risk factor management and anti-ischemic therapies, with revascularization reserved for individuals whose symptoms persist or progress despite intensive medical therapy. Despite these recommendations, many patients undergo revascularization, often because of emotional or psychological factors on the part of both patients and physicians. More than 1 million percutaneous coronary interventions (PCIs) are performed annually in the United States. Although estimates vary, it appears that at least one-half of all PCIs in the United States are performed electively.
The COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial recently demonstrated that, compared with a strategy of PCI plus optimal medical therapy, an initial strategy of optimal medical therapy alone, with PCI reserved for those with refractory angina, had similar rates of death or nonfatal myocardial infarction in individuals with stable CAD who had undergone coronary angiography before randomization. Also, over a median follow-up of 4.6 years, only 33% of individuals randomized to the optimal medical therapy group required revascularization, suggesting that two-thirds of individuals with stable CAD could potentially avoid PCI during this time period if treated initially with optimal medical therapy alone.
Because clinical trial populations tend to be more adherent and health conscious, it is not clear to what extent individuals with stable CAD in the United States achieve the risk factor goals used in the COURAGE trial. Therefore, using data on participants who reported a history of CAD at baseline in the national REGARDS (REasons for Geographic and Racial Differences in Stroke) study, we sought to examine the proportion of individuals with risk factor levels similar to the goals used in the COURAGE trial. Additionally, we examined sociodemographic factors associated with being at these risk factor goals.
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