Adherence level of antihypertensive agents in coronary artery disease

AIMS

Antihypertensive (AH) agents have been shown to reduce the risk of cardiovascular events, including coronary artery disease (CAD). Previous surveys have shown that a substantial number of patients with diagnosed hypertension remain uncontrolled. Non-adherence to AH agents may reduce the effectiveness. The aim was to evaluate the impact of better adherence to AH agents on the occurrence of CAD in a real clinical setting.

METHODS

A cohort of 83 267 patients was reconstructed using the Régie de l''assurance maladie du Québec databases. Patients were eligible if they were between 45 and 85 years of age without indication of cardiovascular disease, and had been newly treated with AH agents between 1999 and 2004. A nested case–control design was used to study the incidence of CAD. Every case of CAD was matched for age and duration of follow-up to up to 15 randomly selected controls. The adherence level was measured by calculating the medication possession ratio. Cases'' adherence was calculated from the start of follow-up to the time of the CAD (index date). For controls, adherence was calculated from the start of follow-up to the time of selection (index date). Rate ratios of CAD were estimated by conditional logistic regression adjusting for covariables.

RESULTS

The mean patient age was 65 years, 37% were male, 8% had diabetes and 18% had dyslipidaemia. High adherence level (96%) to AH therapy compared with lower adherence level (59%) was associated with a relative risk reduction of CAD events (rate ratios 0.90; 0.84, 0.95). Risk factors for CAD were male gender, diabetes, dyslipidaemia and developing a cardiovascular condition disease during follow-up.

CONCLUSION

Our study suggests that better adherence to AH agents is associated with a risk reduction of CAD. Adherence to AH agents needs to be improved so that patients can benefit from the full protective effects of AH therapies.     

Statin adherence and the risk of major coronary events in patients with diabetes: a nested case-control study

AIMS

To evaluate whether good statin adherence is associated with a reduced incidence of major coronary events (MCEs) among diabetic patients with and without coronary heart disease (CHD).

METHODS

Using data derived by linkage of nationwide health databases in Finland, we conducted a nested case–control analysis of 3513 cases with an MCE, a composite of acute myocardial infarction and/or coronary revascularization, and 20 090 matched controls identified from a cohort of 60 677 statin initiators with diabetes. Cases and controls were matched according to gender, time of cohort entry and duration of follow-up and further classified to two risk groups according to the presence of CHD at statin initiation. The incidence of MCEs was compared between patients with good statin adherence (the proportion of days covered ≥80%) and patients with poor statin adherence (<80%). Odds ratios (OR) for MCEs were estimated by conditional logistic regression adjusting for several covariables.

RESULTS

Good statin adherence was associated with a reduced incidence of MCEs in those with prior CHD [OR 0.84 (95% CI 0.74–0.95)] and in those without it [OR 0.86 (95% CI 0.78–0.95)]. The association persisted among those followed up for 5 years or longer [OR 0.77 (95% CI 0.58–1.02) and OR 0.79 (95% CI 0.66–0.94) respectively]. In sensitivity analyses, a reduced MCE incidence was observed also in those without any documented cardiovascular disease (CVD) at statin initiation [OR 0.87 (95% CI 0.78–0.96) overall and OR 0.80 (95% CI 0.66–0.97) for those followed up 5 years or longer].

CONCLUSIONS

In patients with diabetes, good adherence to statins predicts reduced incidence of MCEs irrespective of the presence of CHD at statin initiation.     

Impact of better adherence to statin agents in the primary prevention of coronary artery disease

Background  

Statins reduce cardiovascular morbidity and mortality after continuous treatment. Studies have shown that less than 50% of patients take 80% or more of prescribed doses 1 year after starting therapy.     

杂交冠状动脉血运重建术与CABG治疗多支冠状动脉疾病中远期随访的Meta分析

目的 系统评价杂交冠状动脉血运重建术（HCR）与冠状动脉旁路移植术（CABG）治疗多支冠状动脉疾病 中远期疗效与并发症。方法 系统检索Embase、PubMed、Web of Science、Cochrane Central Registry of Controlled Trials （Central）、万方数据、中国知网,筛选符合纳入标准的文献,并计算每项研究中的比值比（odds ratio,OR）和95%置信 区间（95%CI）,采用RevMan 5.3软件进行Meta分析。结果 9篇文献纳入研究,累计研究对象4 030例,其中1 142例 接受HCR治疗,2 888例接受传统CABG治疗。Meta分析结果显示：（1）中远期随访中HCR组术后全因病死率（OR= 0.72,95%CI：0.54～0.96）和主要心脑血管事件（MACCE,OR=0.54,95%CI：0.35～0.82）均低于CABG组。而在血运重 建（OR=0.90,95%CI：0.61～1.34）及心肌梗死或心绞痛发生率（OR=0.51,95%CI：0.18～1.41）方面差异无统计学意义。 （2）中期随访中 HCR 组的 MACCE 发生率低于 CABG 组（OR=0.31,95%CI：0.15～0.66）,而全因病死率（OR=0.79, 95%CI：0.52～1.22）、血运重建（OR=0.77,95%CI：0.30～1.96）以及心肌梗死或心绞痛发生率（OR=0.71,95%CI：0.05～ 9.46）等差异无统计学意义。（3）远期随访中HCR组术后全因病死率（OR=0.67,95%CI：0.46～0.98）及心肌梗死或心绞 痛发生率（OR=0.32,95%CI：0.15～0.68）均低于 CABG 组。而在 MACCE（OR=0.72,95%CI：0.43～1.21）与血运重建 （OR=0.93,95%CI：0.60～1.45）方面差异无统计学意义。结论 HCR相比CABG可降低多支冠状动脉病变患者的中 期MACCE和远期全因病死率、心肌梗死或心绞痛发生率。     

经桡动脉和股动脉途径介入治疗复杂冠状动脉病变的临床疗效分析

目的探讨不同介入途径治疗复杂冠状动脉病变的临床疗效和可行性。方法选取614例有复杂冠状动脉病变冠心病患者,其中经桡动脉途径患者304例（桡动脉组）,股动脉途径患者310例（股动脉组）,观察介入手术成功率、卧床时间、术后发生并发症等情况。结果 2组患者在年龄、性别、危险因素等方面比较,差异均无统计学意义（P〉0.05）;桡动脉组手术成功率为97.7%,股动脉组为98.1%,2组成功率差异无统计学意义（P〉0.05）;桡动脉组术后并发症发生率明显低于股动脉组（P〈0.05）;卧床时间明显短于股动脉组（P〈0.05）;平均住院时间及住院期间主要心血管事件发生率差异无统计学意义（P〉0.05）。结论经桡动脉途径介入治疗冠状动脉复杂病变成功率高,且术后并发症发生率低,不增加心血管事件。     

C反应蛋白与冠状动脉病变程度相关研究

目的 探讨冠状动脉病变患者血清C反应蛋白水平及其与冠状动脉病变严重程度的关系.方法 采用胶乳增强免疫比浊法测定经冠状动脉造影证实的管腔直径狭窄＞50%～95%冠状动脉病变患者血清C反应蛋白水平,与年龄、性别相匹配的冠状动脉造影证实的非冠状动脉病变患者进行比较.结果 冠状动脉病变患者血清C反应蛋白水平明显高于对照组（P＜0.05）,重度狭窄组血清c反应蛋白明显高于中度狭窄组（P＜0.05）.结论 冠状动脉病变患者血清C反应蛋白水平明显升高,可反映冠状动脉病变的严重程度.因此血清C反应蛋白水平可作为冠状动脉病变程度的参考指标之一.     

冠状动脉钙化积分及相关临床因素对老年冠心病的诊断研究

目的探讨多层螺旋CT冠状动脉钙化积分（CACS）及相关临床因素在老年冠心病诊断中的价值。方法入选疑诊冠心病患者106例,所有患者均行多层螺旋CT测量CACS、冠状动脉造影、外周血管彩超、心脏彩超以及相关血液生化检查。根据造影结果分为冠心病组62例（冠状动脉狭窄≥50%）,非冠心病组44例（冠状动脉狭窄〈50%）,并对冠状动脉病变严重程度进行评分。结果与对照组相比,冠心病组CACS值明显升高,且CACS值随冠状动脉狭窄程度及病变严重程度加重而增加。冠心病组颈动脉内中膜厚度（IMT）、股动脉IMT、瓣膜钙化以及血压、血脂、空腹血糖、C-反应蛋白与非冠心病组相比,差异具有统计学意义。冠心病组中瓣膜钙化较非钙化者CACS值明显升高,差异具有统计学意义。结论 CACS值与外周血管彩超、心脏彩超和相关血液生化检查相结合,能更好的预测老年冠心病的发生、发展。     

他汀类药物联合依折麦布用于冠心病患者治疗的有效性和安全性评价

目的:研究中强度他汀联用依折麦布在冠状动脉粥样硬化性心脏病患者中与中、高强度他汀单用的有效性与安全性差异。方法:检索北京安贞医院HIS系统中2018年1月至2019年4月门诊及住院数据库,筛选出住院就诊记录后3~5周有门诊复查记录的病例。根据病例所使用的他汀类药物分为中强度他汀组、中强度他汀联用依折麦布组及高强度他汀组。比较门诊记录与住院记录血脂指标变化及变化率,并以门诊记录的低密度脂蛋白胆固醇(LDL-C)值,评估病例降脂目标达成率,对比各组降脂疗效的差距。以门诊记录病例中谷草转氨酶(AST)、谷丙转氨酶(ALT)以及肌酸激酶(CK)值超过正常上限2倍及3倍的人数,评估各组安全性差异。结果:共有371例患者纳入研究。联用组降脂目标达成率显著高于中、高强度他汀组;联用组LDL-C绝对变化、相对变化均显著优于中、高强度他汀组(P＞0.05);安全性无显著差异(P＜0.05)。结论:对于冠状动脉粥样硬化性心脏病患者的降脂治疗,中强度他汀联用依折麦布治疗方案降脂效果优于中、高强度他汀单用,且安全性无显著差异。     

颈动脉粥样硬化与冠心病的相关性研究

目的：探讨颈动脉粥样硬化和冠心病之间的关系。方法：对42例疑似冠心病的患者同时作颈动脉超声和冠脉造影检壹。结果：30例冠脉造影阳性,其中25例颈动脉超声发现粥样斑块。结论：无创性的颈动脉超声检测可以间接反映冠心病。     

冠心病患者冠脉严重程度与冠心病危险因素的相关性分析

目的探讨冠心病患者冠状动脉(冠脉)严重程度与冠心病危险因素的相关性。方法 80例行冠状动脉造影检查者,按病变程度分为观察组(经冠状动脉造影确诊的冠心病患者)和对照组(冠状动脉粥样硬化狭窄程度<10%的患者),各40例。回顾性分析两组患者的临床资料;分析冠心病患者及冠状动脉病变程度的相关因素。结果冠心病重度病变患者吸烟例数少于中度和轻度病变患者, 2型糖尿病、高血压例数多于轻度病变患者, LVEF异常例数少于轻度病变患者,差异具有统计学意义(P<0.05)。Logistic分析结果显示,吸烟、2型糖尿病、高血压与冠状动脉病变程度相关(P<0.05)。结论 2型糖尿病、高血压、吸烟、男性为冠心病的危险因素,且冠状动脉病变程度与患者的左心功能降低有关,由此,积极控制与冠状动脉病变关系更大的冠心病危险因素,可以早期防治冠心病进一步恶化的发生,减少冠状动脉狭窄与后期严重并发症的出现。     

Intensive lipid-lowering therapy in coronary artery disease: implications of the REVERSAL and PROVE-IT trials

Current international guidelines recommend that the goal of treatment with lipid-lowering therapy in patients with established coronary artery disease (CAD) should be a low-density lipoprotein cholesterol level of < 100 mg/dl. The question that remains to be answered is whether more aggressive lowering of low-density lipoprotein cholesterol levels below this target offers additional benefit and whether it can be tolerated. Two recently published related studies addressed this question by comparing intensive lipid lowering with atorvastatin (Lipitor^®, Pfizer) 80 mg/day with a moderate lipid-lowering regimen of pravastatin (Pravachol^®, Bristol-Myers Squibb) 40 mg/day. The first study, the Reversing Atherosclerosis with Aggressive Lipid Lowering (REVERSAL) compared the effect of the two regimens on coronary artery atheroma burden and progression using intravascular ultrasound in patients with symptomatic CAD. The second study, the Pravastatin or Atorvastatin Evaluation and Infection Therapy (PROVE-IT) was a clinical outcome trial in patients recently hospitalised with acute coronary syndromes. This article reviews the implications of these two studies in the management of patients with CAD. In addition, other ongoing trials and future directions are explored.     

辛伐他汀对冠心病患者血清内脂素水平的影响

目的:研究冠心病患者血清内脂素水平的变化以及辛伐他汀治疗对其水平的影响。方法:选取78例合并轻度血脂升高冠心病患者和62名健康对照者,检测2组的血清内脂素水平有无差异。78例冠心病患者再进一步随机分为常规治疗组和辛伐他汀组,每组39例,观察2组在治疗前后血清内脂素水平的变化。结果:与正常对照组相比,冠心病患者的血清内脂素水平显著升高,差异有统计学意义。血清内脂素与体重指数、收缩压、空腹血糖、胰岛素抵抗指数和三酰甘油呈正相关,而与高密度脂蛋白胆固醇呈负相关。治疗4周后,辛伐他汀组的血清内脂素水平较治疗前明显下降,差异有统计学意义;而常规治疗组的血清内脂素水平无明显变化,差异无统计学意义。结论:辛伐他汀具有降低冠心病患者血清内脂素的作用。     

Meta‐analysis of the role of high‐dose statins administered prior to percutaneous coronary intervention in reducing major adverse cardiac events in patients with coronary artery disease

1. There is considerable evidence regarding the efficacy of statins for the primary and secondary prevention of coronary artery disease (CAD). However, due to lack of sufficient evidence, there is still doubt whether high‐dose statin therapy prior to percutaneous coronary intervention (PCI) is beneficial. In the present study, we performed a meta‐analysis to evaluate the effect of preoperative high‐dose statin therapy on the incidence of major adverse cardiac events (MACE) after successful PCI. 2. Trials were retrieved through Medline (1980–2009) and the reference files limited to English‐language articles. Data were abstracted using a standardized protocol and a meta‐analysis was performed. 3. Five studies of a total 1789 patients with CAD qualified for analysis. Administration of high‐dose statins in CAD patients before PCI was associated with a significant reduction in MACE 30 days after the procedure. The incidence of MACE in the high‐dose statin group (6.98%) was significantly lower than that in the placebo group (14.77%), with an odds ratio (OR) of 0.43 (95% confidence interval (CI) 0.31–0.59; P < 0.00001). The incidence of post‐PCI increases in creatine kinase MB in the high‐dose statin and placebo groups was 9.20%vs 18.83%, respectively (OR 0.43; 95% CI 0.33–0.58; P < 0.00001), whereas the incidence of increases in troponin I was 30.13%vs 44.53%, respectively (OR 0.53; 95% CI 0.43–0.67; P < 0.00001), respectively. 4. In conclusion, high‐dose statin therapy before PCI provides a significant benefit over placebo in preventing post‐PCI MACE. Findings from the present analysis strongly support a strategy of routine loading of high‐dose statins before interventional therapy.     

Pharmacotherapy for end-stage coronary artery disease

Importance of the field: Coronary artery disease remains the leading cause of mortality in the industrialized world. Despite advances in surgical and catheter-based interventions, a select number of patients remain with no options for invasive therapy. The goal of this review is to discuss the current status of pharmacotherapeutic interventions to treat end-stage coronary artery disease.

Areas covered in this review: Literature review on the topic of therapeutic angiogenesis from 1980 to 2009.

What the reader will gain: Insight into current therapeutic strategies employed to manage end-stage coronary artery disease.

Take home message: A promising approach focuses on augmenting the endogenous angiogenic response to chronic myocardial ischemia via the use of growth factors.     

血管紧张肽转换酶抑制药在冠心病治疗中的应用

血管紧张肽转换酶抑制药可通过改善心肌供氧耗氧平衡、改善血管内皮功能、抑制交感神经兴奋性、抑制血管平滑肌迁移和增殖、抑制血小板聚集和促进纤维蛋白溶解、抑制低密度脂蛋白氧化修饰、抑制心肌肥厚、延迟心脏重构等机制在动脉粥样硬化和冠心病的治疗中发挥重要作用     

Gene therapy for coronary and peripheral artery disease

Background: Coronary and peripheral artery diseases are highly prevalent diseases, which are characterised by an unmet medical need in the more advanced stages of disease. These comprise the need for vessel regeneration using therapeutic angiogenic gene therapy as well as the prevention of restenosis post-angioplasty using local gene therapy. Both problems have been addressed by extensive research. Objective: Therefore, this article reviews the patents for therapeutic strategies using gene therapy for the prevention of restenosis and induction of therapeutic angiogenesis in the years 1994 – 2008. Methods: Current publications, websites and patents of a number of potentially suitable gene constructs are reviewed. Conclusion: Cardiovascular gene therapy, particularly in therapeutic angiogenesis, has quietly made its way to the first Phase III approval gene therapy trial. There are chances for more gene constructs to reach this stage.     

Statins and coronary artery bypass graft surgery: preoperative and postoperative efficacy and safety

Background: In patients with native coronary artery disease, strong evidence supports the use of statins to reduce the risk of recurrent cardiovascular events and improve survival. However, for patients undergoing coronary artery bypass graft surgery (CABG), statins appear to be underutilized, and concerns have been raised regarding their perioperative safety. Objective: The goal of this systematic review is to evaluate the safety and efficacy of statin therapy before and after coronary surgical revascularization. Methods: A systematic review was performed to retrieve relevant articles from the Medline database published between 1987 and January 2009. Results: Administered before CABG, statins have been demonstrated to reduce perioperative mortality, stroke and atrial fibrillation. Preoperative statin therapy also reduces the systemic inflammatory response associated with cardiopulmonary bypass. Following CABG, statins inhibit saphenous vein graft disease and the progression of atherosclerosis in native coronary arteries. In addition, postoperative statins reduce the recurrence of cardiovascular events and improve all-cause mortality. High-intensity lipid reduction to achieve low-density lipoprotein levels to 70 mg/dl may benefit post-CABG patients, but this has yet to be evaluated prospectively. Adverse effects related to perioperative statin therapy seem to be extremely rare, and little data are available to support the practice of withholding statin therapy before or after surgery. Conclusion: Numerous studies have demonstrated that statins improve the outcomes of patients undergoing CABG. The benefits seem to outweigh the risks associated with their use, both in the preoperative and postoperative period. In the absence of contraindications, essentially all CABG patients are candidates for life-long statin therapy that ideally should be started before surgery. The optimal postoperative statin regimen remains unknown and should be the subject of future study.