Predictors and Outcomes of Routine Versus Optimal Medical Therapy in Stable Coronary Heart Disease

Chun, Soohun; Qiu, Feng; Austin, Peter C.; Ko, Dennis T.; Mamdani, Muhammad; Wijeysundera, Duminda N.; Czarnecki, Andrew; Bennell, Maria C.; Wijeysundera, Harindra C.

doi:10.1016/j.amjcard.2015.05.035

Cited by 7 publications

(7 citation statements)

References 14 publications

(19 reference statements)

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“…10,11 In clinical practice, it is not different, as several registrybased analyses have shown. 12,13 As mentioned, in the present study, the PCI:CABG ratio in BC in 2014 was 0.88. 9 Although this represents a decline from the pre-FREEDOM ratio (1.59), this figure also shows that approximately 47% of the patients with diabetes and multivessel disease were still receiving PCI.…”

supporting

confidence: 61%

Translating Scientific Evidence Into Clinical Practice: Closing the Loop

Farkouh

2020

Canadian Journal of Cardiology

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See article by Miller et al., pages 1236e1243 of this issue.Clinical practice guidelines recommend coronary artery bypass surgery (CABG) as the optimal revascularization strategy in patients with diabetes and multivessel coronary disease. [1][2][3] Although many trials have studied this issue, the Future Revascularization Evaluation in Patients With Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) was the first adequately powered trial to compare CABG vs percutaneous coronary intervention (PCI) with drug-eluting stents in patients with diabetes, in addition to optimal medical therapy. 4 A total of 1900 patients were randomized and, after a median follow-up of 3.8 years, CABG, compared with PCI, reduced the composite of allcause mortality, nonfatal myocardial infarction, and stroke (18.7% vs 26.6%; P ¼ 0.005). 4 A long-term follow-up of this trial (median of 7.5 years) showed that PCI was associated with excess mortality, with a hazard ratio of 1.36 (95% confidence interval [CI], 1.07-1.74; P ¼ 0.01). 5 A pooled analysis of patient-level data from 11 clinical trials, including 3266 patients with diabetes and multivessel disease, also corroborated these findings. 6 The results of the FREEDOM trial were first presented at the American Heart Association Congress on November 4, 2012 and simultaneously published online. 4 The FREEDOM results were gradually incorporated into clinical practice guidelines internationally. [1][2][3] The ultimate goal of clinical research is to inform clinical practice, providing better care to our patients. This process usually begins at the bedside, by recognizing a knowledge gap, which will lead to a clinically relevant research question to be pursued in a trial. The cycle is completed when the scientific evidence generated by the trial is incorporated into guidelines and ultimately into clinical practice, benefiting patients. Although

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confidence: 61%

Translating Scientific Evidence Into Clinical Practice: Closing the Loop

Farkouh

2020

Canadian Journal of Cardiology

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“…Although there is no universal definition of OMT, these medications are strongly recommended by contemporary guidelines as class 1 indications and have been used in previous publications investigating the use of OMT in patients with stable CAD . Aspirin, although a strong recommendation, was not included in our analysis because it can be obtained over the counter in Ontario, which is not captured in the available databases.…”

Section: Methodsmentioning

confidence: 99%

“…Multiple landmark studies have established the importance of these recommended therapies; however, this evidence has been principally demonstrated in patients with chronic CAD with significant obstructive coronary lesions 3. More important, up to 62% of patients with chronic CAD undergoing elective coronary angiography have nonobstructive coronary lesions 4, 5, 6…”

mentioning

confidence: 99%

“…The mainstay of treatment for stable coronary artery disease (CAD) is optimal medical therapy (OMT) alone or in combination with revascularization, by either coronary artery bypass grafting or percutaneous coronary intervention . Multiple landmark studies have established the importance of these recommended therapies; however, this evidence has been principally demonstrated in patients with chronic CAD with significant obstructive coronary lesions . More important, up to 62% of patients with chronic CAD undergoing elective coronary angiography have nonobstructive coronary lesions …”

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confidence: 99%

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Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Oxner

Elbaz‐Greener

Qui

et al. 2017

JAHA

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BackgroundThere is a paucity of data on the need for optimal medical therapy (OMT) in nonobstructive coronary artery disease . We sought to understand if there was variation in the use of OMT between hospitals for patients with nonobstructive coronary artery disease, the factors associated with such variation, and its clinical consequences.Methods and ResultsUsing a population‐level clinical registry in Ontario, Canada, we identified all patients >66 years undergoing coronary angiography for the indication of stable angina, who had nonobstructive coronary artery disease between November 1, 2010, and October 31, 2013. Hierarchical multivariable logistic models were developed to identify the factors associated with OMT use, with median odds ratio used to quantify the degree of variation between hospitals not explained by the modeled risk factors. Clinical outcomes of interest were all‐cause mortality and rehospitalization, with follow‐up until March 31, 2015. Our cohort consisted of 5413 patients, of whom 2554 (47.2%) were receiving OMT within 1 year. There was a 2‐fold variation in OMT across hospitals (30.4%–61.8%). The variation between hospitals was fully explained by preangiography medication use (median odds ratio of 1.21 in the null model and 1.03 in the full model). There was no difference in risk‐adjusted mortality (hazard ratio, 0.94; 95% confidence interval, 0.76–1.16); however, patients receiving OMT had a lower risk of all‐cause hospital readmission (hazard ratio, 0.89; 95% confidence interval, 0.84–0.95).ConclusionsThere is wide variation in the use of OMT in patients with nonobstructive coronary artery disease, the major driver of which is differences in baseline medication use.

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“…In a Canadian study of more than 20,000 patients with stable CAD aged ≥65 years old, the use of optimal medical therapy (defined as a beta blocker, ARB/ACE inhibitor, and statin) was 61%. Aspirin could not be included in the analysis because of database limitations [34].…”

Section: Current Treatment Approachesmentioning

confidence: 99%

Burden of Coronary Artery Disease and Peripheral Artery Disease: A Literature Review

Bauersachs

Zeymer

Brière

et al. 2019

Cardiovascular Therapeutics

267

153

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Background. Atherothrombotic disease, including coronary artery disease (CAD) and peripheral artery disease (PAD), can lead to cardiovascular (CV) events, such as myocardial infarction, stroke, limb ischemia, heart failure, and CV death. Aim. Evaluate the humanistic and economic burden of CAD and PAD and identify unmet needs through a comprehensive literature review. Methods. Relevant search terms were applied across online publication databases. Studies published between January 2010 and August 2017 meeting the inclusion/exclusion criteria were selected; guidelines were also included. Two rounds of screening were applied to select studies of relevance. Results. Worldwide data showed approximately 5–8% prevalence of CAD and 10–20% prevalence of PAD, dependent on the study design, average age, gender, and geographical location. Data from the REACH registry indicated that 18–35% of patients with CAD and 46–68% of patients with PAD had disease in one or more vascular beds. Use of medication to control modifiable CV risk factors was variable by country (lower in France than in Canada); statins and aspirin were the most widely used therapies in patients with chronic disease. Survival rates have improved with medical advancements, but there is an additional need to improve the humanistic burden of disease (i.e., associated disability and quality of life). The economic burden of atherothrombotic disease is high and expected to increase with increased survival and the aging population. Conclusion. CAD and PAD represent a substantial humanistic and economic burden worldwide, highlighting a need for new interventions to reduce the incidence of atherothrombotic disease.

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Predictors and Outcomes of Routine Versus Optimal Medical Therapy in Stable Coronary Heart Disease

Cited by 7 publications

References 14 publications

Translating Scientific Evidence Into Clinical Practice: Closing the Loop

Translating Scientific Evidence Into Clinical Practice: Closing the Loop

Variations in Use of Optimal Medical Therapy in Patients With Nonobstructive Coronary Artery Disease: A Population‐Based Study

Burden of Coronary Artery Disease and Peripheral Artery Disease: A Literature Review

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