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Canadian Journal of Cardiology

Cholesterol End Points Predict Outcome in Patients With Coronary Disease: Quality Improvement Metrics from The Enhancing Secondary Prevention in Coronary Artery Disease (ESP-CAD) Trial

      Abstract

      Background

      Achievement of target low-density lipoprotein (LDL) levels for secondary prevention is endorsed in Canadian guidelines but has been de-emphasized in the 2013 American College of Cardiology/American Heart Association coronary artery disease (CAD) guidelines in favor of initiation of statins or triple therapy (antiplatelet agent, angiotensin converting enzyme inhibitor/angiotensin II receptor blocker, and statins). Our objective was to determine which of these 3 process-of-care metrics achieved within 6 months would be associated with 5-year rates of death, myocardial infarction, or stroke and thus be suitable as an end point for quality improvement studies in patients with CAD.

      Methods

      This was a cohort study that followed 448 participants for 5 years after their involvement in a 6-month secondary prevention trial.

      Results

      Over 5 years, 37 patients died, 23 had myocardial infarction, and 20 had stroke. Six months after randomization, 125 (27.9%) had achieved the LDL target (≤ 2.0 mmol/L), 399 (89.1%) received statins, and 256 (57.1%) received triple therapy. The 5-year composite event rate was significantly lower in patients who achieved the LDL target during the 6-month trial than in those who did not (8.8% vs 17.3%; adjusted hazard ratio [aHR], 0.52; 95% confidence interval [CI], 0.27-0.99), even accounting for statin use (adjusted P = 0.038). Conversely, 5-year event rates were not lower in patients taking statins at 6 months compared with those who were not (14.8% vs 16.3%; aHR, 1.23; 95% CI, 0.58-2.61) or in those receiving triple therapy and those who were not (14.5% vs 15.6%; aHR, 1.17; 95% CI, 0.71-1.94).

      Conclusions

      Achievement of LDL targets at 6 months is suitable as a metric for CAD quality-improvement studies; medication use alone was not independently associated with longer term outcomes.

      Résumé

      Introduction

      L’atteinte des taux cibles de lipoprotéines de faible densité (LDL) dans la prévention secondaire est soutenue par les lignes directrices canadiennes, mais a été abandonnée par les lignes directrices sur la coronaropathie (CP) de l’American College of Cardiology et de l’American Heart Association en faveur de l’introduction des statines ou de la trithérapie (antiplaquettaire, inhibiteur de l’enzyme de conversion de l’angiotensine/bloqueur des récepteurs de l’angiotensine II et statines). Notre objectif était de déterminer laquelle de ces 3 métriques de processus de soins atteintes en 6 mois pourrait être associée à des taux de mortalité, d’infarctus du myocarde ou d’accident vasculaire cérébral dans les 5 ans et, par conséquent, convenir comme critère de jugement des études sur l’amélioration de la qualité des patients souffrant de CP.

      Méthodes

      Il s’agissait d’une étude de cohorte ayant suivi 448 participants jusqu’à 5 ans après leur participation à un essai de 6 mois sur la prévention secondaire.

      Résultats

      Durant les 5 années, 37 patients sont morts, 23 ont subi un infarctus du myocarde et 20 ont subi un accident vasculaire cérébral. Six mois après la répartition aléatoire, 125 (27,9 %) patients avaient atteint la valeur cible du LDL (≤ 2,0 mmol/l), 399 (89,1 %) avaient reçu des statines et 256 (57,1 %) avaient reçu la trithérapie. Le taux d’événements combinés durant 5 ans était significativement plus faible chez les patients qui avaient atteint la valeur cible du LDL au cours de l’essai de 6 mois que chez ceux qui ne l’avaient pas atteinte (8,8 % vs 17,3 %; rapport de risque ajusté [RRa], 0,52; intervalle de confiance [IC] à 95 %, 0,27-0,99), même en tenant compte de l’utilisation des statines (valeur ajustée de P = 0,038). Inversement, les taux d’événements durant 5 ans n’ont pas été plus faibles chez les patients qui avaient pris les statines durant 6 mois que chez ceux qui ne les avaient pas prises (14,8 % vs 16,3 %; RRa, 1,23; IC à 95 %, 0,58-2,61) ou chez ceux qui avaient reçu la trithérapie et chez ceux qui ne l’avaient pas reçue (14,5 % vs 15,6 %; RRa, 1,17; IC à 95 %, 0,71-1,94).

      Conclusions

      L’atteinte des valeurs cibles du LDL après 6 mois convient comme métrique aux études sur l’amélioration de la qualité des cas de CP; l’utilisation de la médication seule n’était pas indépendamment associée à des résultats à plus long terme.
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