International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis

Bhatt, Deepak L.

doi:10.1001/jama.295.2.180

Cited by 1,431 publications

(1,118 citation statements)

References 30 publications

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“…These higher event rates may be driven by a large proportion of patients with CAD (90%). Interestingly, these data are consistent with findings from the REACH registry, which has a large percentage of patients with PAD combined with CAD and is associated with high mortality rates 22. Therefore, accurate risk prediction and identification for underlying pathophysiology in patients with PAD is critically meaningful.…”

Section: Discussionsupporting

confidence: 85%

Trimethylamine N ‐Oxide and Mortality Risk in Patients With Peripheral Artery Disease

Senthong

Wang

Fan

et al. 2016

JAHA

141

110

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BackgroundProduction of the proatherogenic metabolite, trimethylamine N‐oxide (TMAO), from dietary nutrients by intestinal microbiota enhances atherosclerosis development in animal models and is associated with atherosclerotic coronary artery disease in humans. The utility of studying plasma levels of TMAO to risk stratify in patients with peripheral artery disease (PAD) has not been reported.Methods and ResultsWe examined the relationship between fasting plasma TMAO and all‐cause mortality (5‐year), stratified by subtypes of PAD and presence of coronary artery disease in 935 patients with PAD who underwent elective angiography for cardiac evaluation at a tertiary care hospital. Median plasma TMAO was 4.8 μmol/L (interquartile range, 2.9–8.0 μmol/L). Elevated TMAO levels were associated with 2.7‐fold increased mortality risk (fourth versus first quartiles, hazard ratio 2.86, 95% CI 1.82–3.97, P<0.001). Following adjustments for traditional risk factors, inflammatory biomarkers, and history of coronary artery disease, the highest TMAO quartile remained predictive of 5‐year mortality (adjusted hazard ratio 2.06, 95% CI 1.36–3.11, P<0.001). Similar prognostic value for elevated TMAO was seen for subjects with carotid artery, non–carotid artery, or lower extremity PAD. TMAO provided incremental prognostic value for all‐cause mortality (net reclassification index, 40.22%; P<0.001) and improvement in area under receiver operator characteristic curve (65.7% versus 69.4%; P=0.013).Conclusions TMAO, a pro‐atherogenic metabolite formed by gut microbes, predicts long‐term adverse event risk and incremental prognostic value in patients with PAD. These findings point to the potential for TMAO to help improve selection of high‐risk PAD patients with or without significant coronary artery disease, who likely need more aggressive and specific dietary and pharmacologic therapy.

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Section: Discussionsupporting

confidence: 85%

Trimethylamine N ‐Oxide and Mortality Risk in Patients With Peripheral Artery Disease

Senthong

Wang

Fan

et al. 2016

JAHA

141

110

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“…Study details have been described elsewhere 6, 7, 20. In the present study, we included patients with stable clinical coronary artery disease, cerebrovascular disease and/or peripheral artery disease from both cohorts.…”

Section: Methodsmentioning

confidence: 99%

“…In particular with the emergence of novel therapeutic options such as proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, novel anticoagulants, or anti‐inflammatory agents, tools to predict recurrent cardiovascular events are needed 2, 3. Recently, 2 risk scores have been developed for the prediction of recurrent cardiovascular events based on the observational REACH (Reduction of Atherothrombosis for Continued Health) and SMART (Secondary Manifestations of Arterial Disease) cohort studies 4, 5, 6, 7, 8, 9. These scores estimate the 20‐month (REACH) and 10‐year (SMART) risk of recurrent major cardiovascular events in patients with established cardiovascular disease.…”

Section: Introductionmentioning

confidence: 99%

Estimated Life Expectancy Without Recurrent Cardiovascular Events in Patients With Vascular Disease: The SMART‐REACH Model

Kaasenbrood

Bhatt

Dorresteijn

et al. 2018

JAHA

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BackgroundIn patients with vascular disease, risk models may support decision making on novel risk reducing interventions, such as proprotein convertase subtilisin/kexin type 9 inhibitors or anti‐inflammatory agents. We developed and validated an innovative model to estimate life expectancy without recurrent cardiovascular events for individuals with coronary, cerebrovascular, and/or peripheral artery disease that enables estimation of preventive treatment effect in lifetime gained.Methods and ResultsStudy participants originated from prospective cohort studies: the SMART (Secondary Manifestations of Arterial Disease) cohort and REACH (Reduction of Atherothrombosis for Continued Health) cohorts of 14 259 (REACH Western Europe), 19 170 (REACH North America) and 6959 (SMART, The Netherlands) patients with cardiovascular disease. The SMART‐REACH model to estimate life expectancy without recurrent events was developed in REACH Western Europe as a Fine and Gray competing risk model incorporating cardiovascular risk factors. Validation was performed in REACH North America and SMART. Outcomes were (1) cardiovascular events (myocardial infarction, stroke, cardiovascular death) and (2) noncardiovascular death. Predictors were sex, smoking, diabetes mellitus, systolic blood pressure, total cholesterol, creatinine, number of cardiovascular disease locations, atrial fibrillation, and heart failure. Calibration plots showed high agreement between estimated and observed prognosis in SMART and REACH North America. C‐statistics were 0.68 (95% confidence interval, 0.67–0.70) in SMART and 0.67 (95% confidence interval, 0.66–0.68) in REACH North America. Performance of the SMART‐REACH model was better compared with existing risk scores and adds the possibility of estimating lifetime gained by novel therapies.ConclusionsThe externally validated SMART‐REACH model could be used for estimation of anticipated improvements in life expectancy without recurrent cardiovascular events in individual patients with cardiovascular disease in Western Europe and North America.

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“…Several studies have reported underutilization of established risk‐reduction therapies such as statins for peripheral artery disease relative to coronary artery disease,6, 7, 8 which may lead to poor cardiovascular and limb outcomes 9. Nevertheless, few data exist on the utilization of statin therapy among patients with carotid artery disease.…”

Section: Introductionmentioning

confidence: 99%

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

Hussain

Saposnik

Raju

et al. 2018

JAHA

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BackgroundStatins are commonly used for the prevention of cardiovascular events; however, statins are underutilized in patients with noncoronary atherosclerosis. We sought to establish the rates of statin use in patients with carotid artery disease and to examine the association between statin therapy and outcomes after carotid revascularization.Methods and ResultsIn this population‐level retrospective cohort study, we identified all individuals aged ≥66 years who underwent carotid endarterectomy or stenting in Ontario, Canada (2002–2014). The primary outcome was a composite of 1‐year stroke, myocardial infarction, or death (major adverse cardiac and cerebrovascular events). Five‐year risks were also examined. Adjusted hazard ratios were computed using inverse probability of treatment weighting based on propensity scores. A total of 7893 of 10 723 patients (73.6%) who underwent carotid revascularization were on preprocedural statin therapy; moderate‐ or high‐dose therapy was utilized by 7384 patients (68.9%). The composite rate of 1‐year major adverse cardiac and cerebrovascular events was lower among statin users (adjusted hazard ratio: 0.76; 95% confidence interval, 0.70–0.83). Patients who were on persistent long‐term statin therapy after the carotid procedure continued to experience significantly lower risk of major adverse cardiac and cerebrovascular events at 5 years (adjusted hazard ratio: 0.75, 95% confidence interval, 0.71–0.80). The beneficial associations with statin use were observed regardless of type of carotid revascularization procedure, carotid artery symptom status, or statin dose.ConclusionsContinuous statin therapy was associated with a 25% lower risk of long‐term adverse cardiovascular events in patients with significant carotid disease. Along with other supportive evidence, statins should be considered in patients undergoing carotid revascularization, and efforts are required to increase statin use in this undertreated population.

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International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis

Abstract: This large, international, contemporary database shows that classic cardiovascular risk factors are consistent and common but are largely undertreated and undercontrolled in many regions of the world.

Cited by 1,431 publications

References 30 publications

Trimethylamine N ‐Oxide and Mortality Risk in Patients With Peripheral Artery Disease

Trimethylamine N ‐Oxide and Mortality Risk in Patients With Peripheral Artery Disease

Estimated Life Expectancy Without Recurrent Cardiovascular Events in Patients With Vascular Disease: The SMART‐REACH Model

Association Between Statin Use and Cardiovascular Events After Carotid Artery Revascularization

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