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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Article info
Publication history
Published online: July 16, 2014
Accepted:
July 6,
2014
Received:
June 4,
2014
Footnotes
See page 1631 for disclosure information.
ESP-CAD trial Registration: Clinicaltrials.gov identifier NCT00175240.
Identification
Copyright
© 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.
