Atherothrombosis patients world-wide often have undertreated, undercontrolled risk factors

A large international study demonstrates that patients world-wide with atherothrombosis (coronary artery disease, cerebrovascular disease, peripheral arterial disease) often have cardiovascular risk factors such as obesity and hypertension that are undertreated and undercontrolled, according to a report in the January 11 issue of JAMA.

Atherothrombosis is the leading cause of cardiovascular illness and death around the globe, according to background information in the article. To date, no single international database has characterized the atherosclerosis risk factor profile or treatment intensity of individuals with atherothrombosis. The Reduction of Atherothrombosis for Continued Health (REACH) Registry was designed to provide these data from the most geographically and ethnically diverse population yet surveyed.

Deepak L. Bhatt, M.D., of The Cleveland Clinic, and colleagues analyzed data from the REACH Registry to determine the prevalence and treatment of atherosclerosis risk factors. The Registry included 67,888 patients aged 45 years or older from 5,473 physician practices in 44 countries who had either established arterial disease (coronary artery disease [CAD], n = 40,258; cerebrovascular disease, n = 18,843; peripheral arterial disease, n = 8,273) or 3 or more risk factors for atherothrombosis (n = 12,389) between 2003 and 2004.

The researchers found that atherothrombotic patients throughout the world had similar risk factor profiles: a high proportion with hypertension (81.8 percent), hypercholesterolemia (72.4 percent), and diabetes (44.3 percent). The prevalence of overweight (39.8 percent), obesity (26.6 percent), and morbid obesity (3.6 percent) were similar in most geographic locales, but was highest in North America (overweight: 37.1 percent, obese: 36.5 percent, and morbidly obese: 5.8 percent). Patients were generally undertreated with statins (69.4 percent usage overall), antiplatelet agents (78.6 percent usage overall), and other evidence-based risk reduction therapies. Current tobacco use in patients with established vascular disease was substantial (14.4 percent). Undertreated hypertension (50.0 percent with elevated blood pressure at baseline), undiagnosed hyperglycemia (4.9 percent), and impaired fasting glucose (36.5 percent in those not known to be diabetic) were common.

"The REACH Registry demonstrates a substantial gap between recommendations in guidelines and actual clinical practice in the care of patients with or at risk for atherothrombosis," the authors write. "A pattern of underutilization of established medical therapies and lifestyle interventions is seen in the REACH Registry throughout all geographic regions studied, among different physician specialties, and across disease subtypes. Despite an overwhelming amount of data in support of statins and antiplatelet therapy, these classes of medicines are not being prescribed at optimal rates. A substantial proportion of patients receiving statins are not meeting established targets that are recommended in guidelines for cholesterol reduction, and newer data suggest even more aggressive targets. Only a minority of patients were at target goals for blood pressure, glucose, cholesterol, body weight, and nonuse of tobacco."

"These data demonstrate a strikingly elevated degree of obesity internationally as a critical cardiovascular risk factor," the researchers write. "The percentages of overweight and obese patients support efforts at targeting this risk factor in patients along the atherothrombotic continuum of risk. The follow-up phase of the REACH Registry will allow measurement of the cardiovascular ischemic event rates of this population as well as an assessment of how these various risk factors affect the rate of subsequent morbidity and mortality and cardiovascular outcomes in a geographically diverse population."

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(JAMA. 2006;295:180-189. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: The REACH Registry is sponsored by Sanofi-Aventis, Bristol-Myers Squibb, and the Waksman Foundation (Tokyo). For the financial disclosures of the authors, please see the JAMA article.


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