International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients with Atherothrombosis
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ORIGINAL CONTRIBUTION International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis Deepak L. Bhatt, MD Context Atherothrombosis is the leading cause of cardiovascular morbidity and mor- P. Gabriel Steg, MD tality around the globe. To date, no single international database has characterized E. Magnus Ohman, MD the atherosclerosis risk factor profile or treatment intensity of individuals with athero- thrombosis. Alan T. Hirsch, MD Objective To determine whether atherosclerosis risk factor prevalence and treat- Yasuo Ikeda, MD ment would demonstrate comparable patterns in many countries around the world. Jean-Louis Mas, MD Design, Setting, and Participants The Reduction of Atherothrombosis for Con- Shinya Goto, MD tinued Health (REACH) Registry collected data on atherosclerosis risk factors and treat- ment. A total of 67 888 patients aged 45 years or older from 5473 physician practices Chiau-Suong Liau, MD, PhD in 44 countries had either established arterial disease (coronary artery disease [CAD], Alain J. Richard, MD, PhD n = 40 258; cerebrovascular disease,n=18843; peripheral arterial disease, n = 8273) Joachim Ro¨ther, MD or 3 or more risk factors for atherothrombosis (n = 12 389) between 2003 and 2004. Peter W. F. Wilson, MD Main Outcome Measures Baseline prevalence of atherosclerosis risk factors, medi- cation use, and degree of risk factor control. for the REACH Registry Investigators Results Atherothrombotic patients throughout the world had similar risk factor pro- files: a high proportion with hypertension (81.8%), hypercholesterolemia (72.4%), and ANDOMIZED CONTROLLED diabetes (44.3%). The prevalence of overweight (39.8%), obesity (26.6%), and mor- trials (RCTs) provide the ba- bid obesity (3.6%) were similar in most geographic locales, but was highest in North sis for physicians to practice America (overweight: 37.1%, obese: 36.5%, and morbidly obese: 5.8%; PϽ.001 vs evidence-based medicine and other regions). Patients were generally undertreated with statins (69.4% overall; range: Rhave revolutionized the treatment of 56.4% for cerebrovascular disease to 76.2% for CAD), antiplatelet agents (78.6% over- Ն cardiovascular disorders. Due to their all; range: 53.9% for 3 risk factors to 85.6% for CAD), and other evidence-based strict inclusion and exclusion criteria, risk reduction therapies. Current tobacco use in patients with established vascular dis- ease was substantial (14.4%). Undertreated hypertension (50.0% with elevated blood RCTs do not always provide an accu- pressure at baseline), undiagnosed hyperglycemia (4.9%), and impaired fasting glu- rate view of the burden of disease or cose (36.5% in those not known to be diabetic) were common. Among those with long-term prognosis. In contradistinc- symptomatic atherothrombosis, 15.9% had symptomatic polyvascular disease. tion, registries enable a real-world es- Conclusion This large, international, contemporary database shows that classic car- timation of actual disease treatments. diovascular risk factors are consistent and common but are largely undertreated and In the setting of acute coronary syn- undercontrolled in many regions of the world. dromes, several registries have pro- JAMA. 2006;295:180-189 www.jama.com vided insight into real-world event rates, treatment patterns, and outcomes.1-4 care practices. Although several erothrombosis, but it is restricted to The clinical knowledge base regard- advances based on RCTs have been a particular geographic locale and ing acute coronary syndromes is well- made in the management of athero- does not fully address subsequent risk defined, but no comparable interna- thrombosis,5-9 the number of registries Author Affiliations and the REACH Registry Commit- tional data set is available to describe or population-based studies have been tees and National Coordinators are listed at the end the risk profiles and treatment of limited. The Framingham study, for of this article. Corresponding Author: Deepak L. Bhatt, MD, Cleve- individuals with stable atherothrom- example, continues to provide useful land Clinic Foundation, 9500 Euclid Ave, Desk F25, botic disease as defined in primary data on risk factors for developing ath- Cleveland, OH 44195 ([email protected]). 180 JAMA, January 11, 2006—Vol 295, No. 2 (Reprinted) ©2006 American Medical Association. All rights reserved. INTERNATIONAL PREVALENCE AND TREATMENT OF CARDIOVASCULAR RISK FACTORS of patients with established vascular mented CVD consisted of a hospital or gists), health care environments (rural, disease.10,11 neurologist report with the diagnosis suburban, urban), and medical prac- The Reduction of Atherothrombo- of transient ischemic attack or ische- tices (office-based, hospital-based). This sis for Continued Health (REACH) mic stroke. Documented PAD con- selection was designed to try to mimic Registry was initiated to evaluate out- sisted of 1 or both criteria: current the best available epidemiological data patients who would represent the intermittent claudication with ankle- in each country that reflect the bur- entire spectrum of stable atheroscle- brachial index of less than 0.9 or a his- den of atherothrombosis or at-risk rotic clinical syndromes: from those tory of intermittent claudication populations. The national coordina- with risk factors (but who are asymp- together with a previous and related tor in each country made the final de- tomatic) to those with established intervention, such as angioplasty, cision on the selection of physicians and atherosclerotic arterial disease within stenting, atherectomy, peripheral arte- sites in each country. any circulatory bed. The REACH Reg- rial bypass graft, or other vascular Data were collected centrally via use istry was designed to provide these intervention including amputation. of a standardized international case re- data from the most geographically The risk factors consisted of those port form, completed at the study visit. and ethnically diverse population yet that were documented in the medical Baseline height, weight, waist circum- surveyed.12 This article presents the record or for which patients were re- ference, seated systolic and diastolic baseline characteristics of the REACH ceiving treatment at the time of study blood pressure, and available fasting Registry population. enrollment: treated diabetes mellitus, glucose and cholesterol levels were ob- diabetic nephropathy, ankle-brachial in- tained. From these data, baseline demo- METHODS dex of less than 0.9, asymptomatic ca- graphic and risk factor characteristics The REACH Registry is an interna- rotid stenosis of 70% or higher, ca- were analyzed. Body mass index (BMI) tional, prospective, observational regis- rotid intima media thickness of 2 times was defined as weight in kilograms di- try designed to provide up to 24 months or more adjacent sites, systolic blood vided by the square of height in me- of clinical follow-up. The design of the pressure of 150 mm Hg or higher de- ters. Participants were considered to be REACH Registry has been published spite therapy for at least 3 months, hy- overweight if they had a BMI of 25 to elsewhere.12 Briefly, consecutive eli- percholesterolemia treated with medi- less than 30 or obese if they had a BMI gible outpatients aged 45 years or older cation, current smoking of at least 15 of 30 or higher. Obese participants were with established coronary artery dis- cigarettes per day, men aged 65 years further subclassified as having class I ease (CAD), cerebrovascular disease or older, or women aged 70 years or (BMI, 30-Ͻ35), class II (BMI, 35- (CVD), or peripheral arterial disease older. Patients already in a clinical trial, Ͻ40), or class III obesity (BMI Ն40). (PAD), or with at least 3 atherosclero- hospitalized patients, or those who Waist circumference was also used to sis risk factors were enrolled over an ini- might have difficulty returning for a fol- classify patients as obese if it was 40 tial 7-month recruitment period on a low-up visit were excluded from en- inches or larger (Ն102 cm) in men or worldwide basis between December rollment. This protocol was submit- 35 inches or larger (Ն88 cm) in women. 2003 and June 2004; because of regu- ted to the institutional review board in Current smoking was defined as at least latory requirements in Japan, the en- each country according to local require- 5 cigarettes per day on average within rollment in that country was delayed and ments and signed informed consent was the last month before entry into the occurred between August 2004 and De- obtained for all patients. REACH Registry; former smoking was cember 2004. For this reason, and also Selection of physicians to the REACH defined as at least 5 cigarettes per day because of a desire on the part of the Registry was determined at the coun- on average more than 1 month before Japanese REACH investigators to ana- try level. To ensure homogeneity and entry into the REACH Registry. Poly- lyze their data separately, the data from a good representation in the REACH vascular disease was defined as co- Japan were not analyzed together with Registry population, a site selection existent symptomatic (clinically rec- the data from the rest of Asia. Medical method was designed and imple- ognized) arterial disease in 2 or 3 record documentation was required for mented in each participating country territories (coronary, cerebral, and/or establishment of the presence of CAD, by epidemiologists under the supervi- peripheral) within each patient. CVD, or PAD.