Management and Outcomes Among Chinese Hospitalized Patients With Established Cardiovascular Disease or Multiple Risk Factors
Angiology 1-6 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319715583429 ang.sagepub.com
Jingang Yang, MD, PhD1, Yuejin Yang, MD, PhD1, Hongqiu Gu, PhD1, Wei Li, PhD1, and Dayi Hu, MD2
Abstract We assessed the management and outcomes among hospitalized patients with coronary artery disease (CAD), stroke, peripheral artery disease (PAD), or with multiple (2) cardiovascular (CV) risk factors (multiple risk factors [MRFs]). We retrospectively studied 3732 hospitalized patients of either CV disease or 2 risk factors for atherothrombosis from October 2004 to January 2005. Outcomes included CV death, myocardial infarction (MI), stroke, and hospitalization for atherothrombotic events. About one-third had disease involving 1 vascular bed. Medication was more intense in patients with CAD than in others. The lowest use of statins and antiplatelet treatment was in the PAD-only group. Patients with PAD experienced a higher CV mortality (5.1%) than the patients with CAD (3.73%) or stroke (4.1%), P < .001. Cardiovascular death ranged from 1.2% for patients with MRFs, 2.8% for patients with 1-bed disease, 4.7% for patients with 2-bed disease to 6.4% for patients with 3-bed disease (P for trend 5.7 mmol/L (220 mg/dL), LDL-C >3.6 mmol/L (130 mg/dL), or treatment with antihyperlipidemic medication. Participants were classified as overweight if they had a body mass index (BMI, kg/m2) of 24 to 27.9 and as obese if they had a BMI of 28 or more.10 Uncontrolled DM was defined as fasting glucose 6.0 mmol/L (110 mg/dL),11 BP 140/90 mm Hg (150/90 mmHg in patients 60 years who do not have DM or chronic kidney disease) for hypertension,12 and LDL-C 100 mg/dL ( 2.6 mmol/L) according to the National Lipid Association recommendations.13
Outcomes The outcomes of interest included all-cause death, CV death, and hospitalization due to CV event (including nonfatal stroke, nonfatal MI, transient ischemic attack, unstable angina, and worsening PAD). Cardiovascular death is defined as death due to CAD or stroke. Death and hospitalization were identified from hospital records or by contacting the participants’ families. Causes of death were investigated using medical records and informant interviews.
Statistical Analysis Continuous variables are expressed as mean + standard deviation (SD). Categorical variables are expressed as frequencies and percentages. Baseline characteristics were analyzed with 1-way analysis of variance for continuous variables and chisquare test for categorical variables. For pairwise comparisons, Bonferroni method was employed to control type I error rate. The Cochran-Armitage trend test was performed to test the trend. Event rates were calculated and adjusted for age and gender. This adjustment was accomplished through logistic model described previously.14 Statistical significance was considered
CAD only stroke only PAD only
8.9%
CAD+stroke CAD+PAD
4.7%
30.1% 12.5%
stroke+PAD CAD+PAD+stroke
Figure 1. Type and distribution of multiple risk factors, monovascular and polyvascular disease at baseline in patients eligible for follow-up. Abbreviations: CAD indicates coronary artery disease; PAD, peripheral artery disease.
as a 2-tailed P < .05. The data were analyzed with SAS 9.3 software (SAS Institute, Cary, North Carolina).
Results During a mean follow-up time of 13.6 + 1.5 months, 309 (8.3%) participants were lost. Baseline characteristics were comparable between those followed completely and those lost to follow-up. Among 3423 participants who were successfully followed up, 734 (21.4%) patients had MRFs, 1032 (30.1%) had CAD only, 429 (12.5%) had stroke only, and 162 (4.7%) had PAD only at baseline. We also found that 1066 (31.1%) patients had disease involving 1 vascular bed, which included 303 (8.9%) with both CAD and stroke, 331 (9.7%) with both CAD and PAD, 187 (5.5%) with both stroke and PAD, and 245 (7.2%) with the triad of CAD, stroke, and PAD (Figure 1). Table 1 shows the baseline characteristics for patients included in the follow-up analysis. The population sample included 36.3% women and the mean age was 68.5 + 10.1 years. The population studied was mainly composed of elderly people, with high rates of several risk factors, particularly hypertension (74.1%), DM (39.8%), and current or former smoker (39.6%). Compared to those with MRFs, those with atherosclerotic vascular disease were older (CAD 70.0 + 9.1 years, stroke 71.0 + 8.6 years, PAD 73.1 + 8.5 years, and MRFs 65.7 + 9.6 years; P < .001), had higher percentage of hypertension (CAD 79.0%, stroke 83.2%, PAD 80.4%, and MRFs 64.3%; P < .001), and hyperlipidemia (CAD 33.9%, stroke 36.8%, PAD 37.1%, and MRFs 29.8%; P < .001). In this population, medication use was not high, with only 65.9%, 36.8%, 57.4%, and 38.3% of all patients receiving antiplatelet agents, statins, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and betablockers, respectively. In general, patients with more arterial bed disease tended to have more drugs. For example, patients with 3-bed diseases had the highest percentage of statins, antiplatelet agents, and ACE inhibitor/ARBs (Table 2).
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Table 1. Baseline Characteristics.
Age, years, mean + SD Men, (%) Diabetes, (%) Hypertension, (%) Hyperlipidemia, (%) BMI, kg/m2, (SD) Current or former smoker, (%) Creatinine, mmol/L, mean + SD Medication Statins, (%) Antiplatelet therapy, (%) ACE inhibitor/ARBs, (%) CCBs, (%) Beta-blockers, (%)
Total (n ¼ 3423)
CAD (n ¼ 1907)
Stroke (n ¼ 1168)
PAD (n ¼ 925)
69.2 + 9.4 1784 (52.1) 1363 (39.8) 2358 (74.1) 1222 (35.7) 24.3 (3.6) 1307 (38.2) 100 + 88
70.0 + 9.1 974 (51.0) 726 (38.0) 1469 (79.0) 763 (33.9) 24.5 (3.6) 754 (39.5) 95 + 61
71.0 + 8.6 643 (55.2) 451 (38.7) 969 (83.2) 428 (36.8) 24.3 (3.7) 468 (41.8) 100 + 84
73.1 453 454 744 343 24.0 392 107
1260 (36.8) 2255 (65.9) 1961 (57.4) 1294 (37.8) 1310 (38.3)
978 (51.2) 1463 (76.6) 1285 (67.2) 708 (37.1) 1021 (53.4)
355 848 567 541 541
367 645 561 396 373
(30.5) (72.9) (48.7) (46.5) (46.5)
Multiple Risk Factors (n ¼ 734)
P Value
+ 8.5 (49.0) (49.1) (80.4) (37.1) (3.7) (40.4) + 76
65.7 + 9.6 376 (51.2) 318 (43.3) 472 (64.3) 219 (29.8) 24.2 (3.5) 237 (32.2) 110 + 126
Angiology 1-6 ª The Author(s) 2015 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0003319715583429 ang.sagepub.com
Jingang Yang, MD, PhD1, Yuejin Yang, MD, PhD1, Hongqiu Gu, PhD1, Wei Li, PhD1, and Dayi Hu, MD2
Abstract We assessed the management and outcomes among hospitalized patients with coronary artery disease (CAD), stroke, peripheral artery disease (PAD), or with multiple (2) cardiovascular (CV) risk factors (multiple risk factors [MRFs]). We retrospectively studied 3732 hospitalized patients of either CV disease or 2 risk factors for atherothrombosis from October 2004 to January 2005. Outcomes included CV death, myocardial infarction (MI), stroke, and hospitalization for atherothrombotic events. About one-third had disease involving 1 vascular bed. Medication was more intense in patients with CAD than in others. The lowest use of statins and antiplatelet treatment was in the PAD-only group. Patients with PAD experienced a higher CV mortality (5.1%) than the patients with CAD (3.73%) or stroke (4.1%), P < .001. Cardiovascular death ranged from 1.2% for patients with MRFs, 2.8% for patients with 1-bed disease, 4.7% for patients with 2-bed disease to 6.4% for patients with 3-bed disease (P for trend 5.7 mmol/L (220 mg/dL), LDL-C >3.6 mmol/L (130 mg/dL), or treatment with antihyperlipidemic medication. Participants were classified as overweight if they had a body mass index (BMI, kg/m2) of 24 to 27.9 and as obese if they had a BMI of 28 or more.10 Uncontrolled DM was defined as fasting glucose 6.0 mmol/L (110 mg/dL),11 BP 140/90 mm Hg (150/90 mmHg in patients 60 years who do not have DM or chronic kidney disease) for hypertension,12 and LDL-C 100 mg/dL ( 2.6 mmol/L) according to the National Lipid Association recommendations.13
Outcomes The outcomes of interest included all-cause death, CV death, and hospitalization due to CV event (including nonfatal stroke, nonfatal MI, transient ischemic attack, unstable angina, and worsening PAD). Cardiovascular death is defined as death due to CAD or stroke. Death and hospitalization were identified from hospital records or by contacting the participants’ families. Causes of death were investigated using medical records and informant interviews.
Statistical Analysis Continuous variables are expressed as mean + standard deviation (SD). Categorical variables are expressed as frequencies and percentages. Baseline characteristics were analyzed with 1-way analysis of variance for continuous variables and chisquare test for categorical variables. For pairwise comparisons, Bonferroni method was employed to control type I error rate. The Cochran-Armitage trend test was performed to test the trend. Event rates were calculated and adjusted for age and gender. This adjustment was accomplished through logistic model described previously.14 Statistical significance was considered
CAD only stroke only PAD only
8.9%
CAD+stroke CAD+PAD
4.7%
30.1% 12.5%
stroke+PAD CAD+PAD+stroke
Figure 1. Type and distribution of multiple risk factors, monovascular and polyvascular disease at baseline in patients eligible for follow-up. Abbreviations: CAD indicates coronary artery disease; PAD, peripheral artery disease.
as a 2-tailed P < .05. The data were analyzed with SAS 9.3 software (SAS Institute, Cary, North Carolina).
Results During a mean follow-up time of 13.6 + 1.5 months, 309 (8.3%) participants were lost. Baseline characteristics were comparable between those followed completely and those lost to follow-up. Among 3423 participants who were successfully followed up, 734 (21.4%) patients had MRFs, 1032 (30.1%) had CAD only, 429 (12.5%) had stroke only, and 162 (4.7%) had PAD only at baseline. We also found that 1066 (31.1%) patients had disease involving 1 vascular bed, which included 303 (8.9%) with both CAD and stroke, 331 (9.7%) with both CAD and PAD, 187 (5.5%) with both stroke and PAD, and 245 (7.2%) with the triad of CAD, stroke, and PAD (Figure 1). Table 1 shows the baseline characteristics for patients included in the follow-up analysis. The population sample included 36.3% women and the mean age was 68.5 + 10.1 years. The population studied was mainly composed of elderly people, with high rates of several risk factors, particularly hypertension (74.1%), DM (39.8%), and current or former smoker (39.6%). Compared to those with MRFs, those with atherosclerotic vascular disease were older (CAD 70.0 + 9.1 years, stroke 71.0 + 8.6 years, PAD 73.1 + 8.5 years, and MRFs 65.7 + 9.6 years; P < .001), had higher percentage of hypertension (CAD 79.0%, stroke 83.2%, PAD 80.4%, and MRFs 64.3%; P < .001), and hyperlipidemia (CAD 33.9%, stroke 36.8%, PAD 37.1%, and MRFs 29.8%; P < .001). In this population, medication use was not high, with only 65.9%, 36.8%, 57.4%, and 38.3% of all patients receiving antiplatelet agents, statins, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), and betablockers, respectively. In general, patients with more arterial bed disease tended to have more drugs. For example, patients with 3-bed diseases had the highest percentage of statins, antiplatelet agents, and ACE inhibitor/ARBs (Table 2).
Downloaded from ang.sagepub.com at CARLETON UNIV on June 16, 2015
Yang et al
3
Table 1. Baseline Characteristics.
Age, years, mean + SD Men, (%) Diabetes, (%) Hypertension, (%) Hyperlipidemia, (%) BMI, kg/m2, (SD) Current or former smoker, (%) Creatinine, mmol/L, mean + SD Medication Statins, (%) Antiplatelet therapy, (%) ACE inhibitor/ARBs, (%) CCBs, (%) Beta-blockers, (%)
Total (n ¼ 3423)
CAD (n ¼ 1907)
Stroke (n ¼ 1168)
PAD (n ¼ 925)
69.2 + 9.4 1784 (52.1) 1363 (39.8) 2358 (74.1) 1222 (35.7) 24.3 (3.6) 1307 (38.2) 100 + 88
70.0 + 9.1 974 (51.0) 726 (38.0) 1469 (79.0) 763 (33.9) 24.5 (3.6) 754 (39.5) 95 + 61
71.0 + 8.6 643 (55.2) 451 (38.7) 969 (83.2) 428 (36.8) 24.3 (3.7) 468 (41.8) 100 + 84
73.1 453 454 744 343 24.0 392 107
1260 (36.8) 2255 (65.9) 1961 (57.4) 1294 (37.8) 1310 (38.3)
978 (51.2) 1463 (76.6) 1285 (67.2) 708 (37.1) 1021 (53.4)
355 848 567 541 541
367 645 561 396 373
(30.5) (72.9) (48.7) (46.5) (46.5)
Multiple Risk Factors (n ¼ 734)
P Value
+ 8.5 (49.0) (49.1) (80.4) (37.1) (3.7) (40.4) + 76
65.7 + 9.6 376 (51.2) 318 (43.3) 472 (64.3) 219 (29.8) 24.2 (3.5) 237 (32.2) 110 + 126
