Harvey D White1, Ralph A H Stewart2, Anthony J Dalby3, Amanda Stebbins4, Christopher P Cannon5, Andrzej Budaj6, Ales Linhart7, Prem Pais8, Rafael Diaz9, Philippe Gabriel Steg10, Sue Krug-Gourley11, Christopher B Granger4, Judith S Hochman12, Wolfgang Koenig13, Robert A Harrington14, Claes Held15, Lars Wallentin15. 1. Green Lane Cardiovascular Service, Auckland City Hospital, University of Auckland, Auckland, New Zealand. Electronic address: harveyw@adhb.govt.nz. 2. Green Lane Cardiovascular Service, Auckland City Hospital, University of Auckland, Auckland, New Zealand. 3. Milpark Hospital, Johannesburg, Republic of South Africa. 4. Duke Clinical Research Institute, Duke Medicine, Durham, NC. 5. Cardiovascular Division, Brigham and Women's Hospital, and Harvard Clinical Research Institute, Harvard Medical School, Boston, MA. 6. Postgraduate Medical School, Grochowski Hospital, Warsaw, Poland. 7. 2nd Department of Medicine, Department of Cardiovascular Medicine, General University Hospital, Prague, Czech Republic. 8. St. John's Research Institute, Bangalore, India. 9. Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina. 10. Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, and Paris University, FACT (French Alliance for Cardiovascular Trials), INSERM, Paris, France; National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London, United Kingdom. 11. Metabolic Pathways and Cardiovascular Therapeutic Area, GlaxoSmithKline, King of Prussia, PA. 12. Department of Medicine, New York University Langone Medical Center, New York, NY. 13. Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany; Deutsches Herzzentrum München, Technische Universität München, Munich, Germany; Deutsches Zentrum fur Herz-Kreislauf-Forschung (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany. 14. Stanford Center for Clinical Research, Department of Medicine, Stanford University, Stanford, CA. 15. Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
Abstract
BACKGROUND: In patients with stable coronary heart disease, it is not known whether achievement of standard of care (SOC) targets in addition to evidence-based medicine (EBM) is associated with lower major adverse cardiovascular events (MACE): cardiovascular death, myocardial infarction, and stroke. METHODS: EBM use was recommended in the STabilisation of Atherosclerotic plaque By Initiation of darapLadIb TherapY trial. SOC targets were blood pressure (BP) <140/90 mm Hg and low-density lipoprotein-cholesterol (LDL-C) <100 mg/dL and <70 mg/dL. In patients with diabetes, glycosylated hemoglobin A1c (HbA1c) < 7% and BP of <130/80 mm Hg were recommended. Feedback to investigators about rates of EBM and SOC was provided regularly. RESULTS: In 13,623 patients, 1-year landmark analysis assessed the association between EBM, SOC targets, and MACE during follow-up of 2.7 years (median) after adjustment in a Cox proportional hazards model. At 1 year, aspirin was prescribed in 92.5% of patients, statins in 97.2%, β-blockers in 79.0%, and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers in 76.9%. MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) compared with LDL-C ≥ 100 mg/dL (hazard ratio [HR] 0.694, 95% CI 0.594-0.811) and lower with LDL-C < 70 mg/dL compared with LDL-C < 100 mg/dL (70-99 mg/dL) (HR 0.834, 95% CI 0.708-0.983). MACE was lower with HbA1c < 7% compared with HbA1c ≥ 7% (HR 0.705, 95% CI 0.573-0.866). There was no effect of BP targets on MACE. CONCLUSIONS: MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) and even lower with LDL-C < 70 mg/dL. MACE in patients with diabetes was lower with HbA1c < 7%. Achievement of targets is associated with improved patient outcomes.
BACKGROUND: In patients with stable coronary heart disease, it is not known whether achievement of standard of care (SOC) targets in addition to evidence-based medicine (EBM) is associated with lower major adverse cardiovascular events (MACE): cardiovascular death, myocardial infarction, and stroke. METHODS: EBM use was recommended in the STabilisation of Atherosclerotic plaque By Initiation of darapLadIb TherapY trial. SOC targets were blood pressure (BP) <140/90 mm Hg and low-density lipoprotein-cholesterol (LDL-C) <100 mg/dL and <70 mg/dL. In patients with diabetes, glycosylated hemoglobin A1c (HbA1c) < 7% and BP of <130/80 mm Hg were recommended. Feedback to investigators about rates of EBM and SOC was provided regularly. RESULTS: In 13,623 patients, 1-year landmark analysis assessed the association between EBM, SOC targets, and MACE during follow-up of 2.7 years (median) after adjustment in a Cox proportional hazards model. At 1 year, aspirin was prescribed in 92.5% of patients, statins in 97.2%, β-blockers in 79.0%, and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers in 76.9%. MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) compared with LDL-C ≥ 100 mg/dL (hazard ratio [HR] 0.694, 95% CI 0.594-0.811) and lower with LDL-C < 70 mg/dL compared with LDL-C < 100 mg/dL (70-99 mg/dL) (HR 0.834, 95% CI 0.708-0.983). MACE was lower with HbA1c < 7% compared with HbA1c ≥ 7% (HR 0.705, 95% CI 0.573-0.866). There was no effect of BP targets on MACE. CONCLUSIONS: MACE was lower with LDL-C < 100 mg/dL (70-99 mg/dL) and even lower with LDL-C < 70 mg/dL. MACE in patients with diabetes was lower with HbA1c < 7%. Achievement of targets is associated with improved patient outcomes.
Authors: Claes Held; Nermin Hadziosmanovic; Philip E Aylward; Emil Hagström; Judith S Hochman; Ralph A H Stewart; Harvey D White; Lars Wallentin Journal: J Am Heart Assoc Date: 2022-01-21 Impact factor: 6.106