Unfavourable risk factor control after coronary events in routine clinical practice

Sverre et al. BMC Cardiovascular Disorders (2017) 17:40 DOI 10.1186/s12872-016-0387-z RESEARCH ARTICLE Open Access Unfavourable risk factor control after coronary events in routine clinical practice Elise Sverre1* , Kari Peersen2, Einar Husebye1, Erik Gjertsen1, Lars Gullestad3, Torbjørn Moum4, Jan Erik Otterstad2, Toril Dammen4 and John Munkhaugen1 Abstract Background: Risk factor control after a coronary event in a recent European multi-centre study was inadequate. Patient selection from academic centres and low participation rate, however, may underscore failing risk factor control in routine clinical practice. Improved understanding of the patient factors that influence risk factor control is needed to improve secondary preventive strategies. The objective of the present paper was to determine control of the major risk factors in a coronary population from routine clinical practice, and how risk factor control was influenced by the study factors age, gender, number of coronary events, and time since the index event. Methods: A cross-sectional study determined risk factor control and its association with study factors in 1127 patients (83% participated) aged 18-80 years with acute myocardial infarction and/or revascularization identified from medical records. Study data were collected from a self-report questionnaire, clinical examination, and blood samples after 2-36 months (median 16) follow-up. Results: Twenty-one percent were current smokers at follow-up. Of those smoking at the index event 56% continued smoking. Obesity was found in 34%, and 60% were physically inactive. Although 93% were taking blood-pressure lowering agents and statins, 46% were still hypertensive and 57% had LDL cholesterol >1.8 mmol/L at follow-up. Suboptimal control of diabetes was found in 59%. The patients failed on average to control three of the six major risk factors, and patients with >1 coronary events (p < 0.001) showed the poorest overall control. A linear increase in smoking (p < 0.01) and obesity (p < 0.05) with increasing time since the event was observed. Conclusions: The majority of coronary patients in a representative Norwegian population did not achieve risk factor control, and the poorest overall control was found in patients with several coronary events. New strategies for secondary prevention are clearly needed to improve risk factor control. Even modest advances will provide major health benefits. Trial registration: Registered at ClinicalTrials.gov (ID NCT02309255). Keywords: Secondary prevention, Coronary heart disease, Risk factors, Guidelines Background Over the recent years, there has been a decline in mortality rates worldwide [1] leaving a large number of coronary heart disease (CHD) patients in need of optimal secondary prevention. A positive trend in acute myocardial event rates and recurrences from 1994-2009 were also found in Norway [2]. The association between modifiable risk factors and CHD is overwhelmingly documented [3], likewise the benefit of achieving risk factor * Correspondence: 1 Department of Medicine, Drammen Hospital, 3004 Drammen, Norway Full list of author information is available at the end of the article control to reduce the risk of subsequent events [3, 4]. Despite evidence-based guidelines [5] and cardiac rehabilitation programs for more than 20 years, the EuroAspire studies revealed that the implementation of secondary prevention is far from optimal, with increasing prevalence of smoking in patients <50 years, physical inactivity, obesity and diabetes [6, 7]. In the European cohort of the REACH Study (2003-2004), 40% of symptomatic cardiovascular disease patients had poor control of at least three of the five risk factors assessed [8]. In the Clarify study conducted a decade later, some © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sverre et al. BMC Cardiovascular Disorders (2017) 17:40 improvements were found, but even in Europe, the best region, 50% did not achieve risk factor control [9]. Even though the abovementioned studies provide valuable data on the quality of secondary prevention, patient selection could potentially be a matter of concern. In EuroAspire IV [6] patient inclusion was conducted mainly from academic centres, with potentially better secondary prevention than general cardiac practice. Furthermore, the average interview rate was 49%, and the remaining non-participants were probably more likely to have an even poorer risk factor control. In other multinational studies [9–11], patient identification and inclusion has been conducted at outpatient clinics, often specialist centres, and patients attending them may be more concerned about their health. Previous prevalence estimates thus most likely overestimate adherence to guidelines in the general population of CHD patients. Estimates based on studies of everyday clinical practice are clearly needed. The reasons for unhealthy lifestyle and low risk factor control are complex and poorly understood and the identification of patient and healthcare factors of importance for coronary risk profile remains a public health priority [5]. The overall aim of the The NORwegian CORonary (NOR-COR) Prevention Study is to identify medical, and psychosocial factors associated with unfavourable risk factor control after a cardiovascular event. The present paper determines control of the six major coronary risk factors based in routine clinical practice, and identifies the influence of age, gender, number of coronary events, and time since the index event. Methods Page 2 of 8 The study was conducted at two Norwegian hospitals (Drammen and Vestfold) with a total catchment of 380,000 inhabitants corresponding to 7.4% of the Norwegian population. The catchment area has a representative blend of city and rural districts and is representative of Norwegian geography, economy, age distribution, morbidity, and mortality [13]. The cardiac rehabilitation program at Drammen Hospital includes a multi-disciplinary one day “heart school”, and exercise training twice per week for 6 weeks. The Hospital of Vestfold provides comprehensive lifestyle intervention described elsewhere [14]. Ethics, consent and permission The study was approved by the Regional Committee of Ethics in Medical Research. All patients signed a written informed consent prior to study participation. Study assessments Medication and co-morbidity at the index event wer (...truncated)