Original research
Prevalence and treatment of cardiovascular risk factors in outpatients with atherothrombosis in the Middle East Alawi A Alsheikh-Ali,1,2 Wael A Al-Mahmeed,1 Avi Porath,3 Ismail Khalil,4 Hisham Mahmoud,5 Deepak L Bhatt,6 P Gabriel Steg,7 on behalf of the REACH Registry Investigators 1
Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates 2 Institute for Clinical Research and Health Policy Studies and Tufts University School of Medicine, Boston, Massachusetts, USA 3 Maccabi Healthcare Services, Tel-Aviv, Israel 4 Division of Vascular Surgery & Wound Care Center, Department of Surgery, American University of Beirut, Beirut, Lebanon 5 Medical Affairs, Sanofi-aventis Gulf Office, Dubai, United Arab Emirates 6 VA Boston Healthcare System and Brigham and Women’s Hospital, Boston, Massachusetts, USA 7 INSERM U-698, Universite´ Paris 7 and AP-HP, Paris, France Correspondence to Dr Alawi A Alsheikh-Ali, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, PO Box 51900, Abu Dhabi, United Arab Emirates; [email protected] Accepted 11 July 2011
ABSTRACT Objective To characterise the risk-factor profile and treatment gaps among patients with, or at risk for, cardiovascular disease in the Middle East. Design Secondary analysis of a prospective observational study. Setting International multicentre study (Reduction of Atherothrombosis for Continued Health). Patients Stable outpatients with established cardiovascular disease or at least three risk factors for atherothrombosis. The present analysis was based on 840 patients from the Middle East. Intervention Observational study without a studyspecific intervention. Main outcome measures A treatment gap was defined as at least one of the following: current cigarette smoking, total cholesterol $200 mg/dl, serum glucose $126 mg/dl or blood pressure of $140/90. Results The majority of Middle Eastern patients had hypertension (80.2%), more than half had a history of diabetes mellitus (52.3%), and a third had hypercholesterolaemia (34.1%). There was a high prevalence of obesity (38.6%), and nearly half the patients were former or current smokers (46%). b-Blockers and angiotensin-converting enzyme inhibitors were the most commonly prescribed antihypertensives (61.1% and 57.5%, respectively). Antiplatelet therapy (most commonly aspirin) and lipid-lowering drugs (most commonly a statin) were used in most patients (90.7% and 85.2%, respectively). Three-quarters of the participants (75.6%) had at least one uncontrolled risk factor. Conclusion Patients with atherothrombosis in the Middle East have a high prevalence of risk factors including alarming rates of diabetes mellitus and obesity. At least one risk factor is uncontrolled in the majority of patients, presenting a pressing need for improving the care of such patients in the Middle East.
INTRODUCTION Cardiovascular disease is the leading cause of morbidity and mortality worldwide.1 2 Over the past half century, our understanding of the epidemiology of and risk factors for cardiovascular disease has led to the development of effective measures to combat the cardiovascular epidemic, and resulted in significant improvements in patient outcomes. A substantial proportion of that improvement in cardiovascular disease outcomes was driven by Heart Asia 2011:77e81. doi:10.1136/ha.2010.003145
implementation of primary and secondary preventive measures in stable outpatients. To date, the vast majority of the literature on patients with, or at high risk for, cardiovascular disease comes from predominantly Western populations in affluent/industrialised countries. NonWestern and mostly developing regions of the world contribute an increasingly greater share to the global burden of cardiovascular disease, yet are greatly under-represented in the literature.3 4 In the Middle East, there is growing recognition that cardiovascular disease and its associated risk factors represent a significant public-health challenge, with some Middle Eastern countries reporting some of the highest rates of diabetes and obesity worldwide.5e9 Nonetheless, relatively few data are available on risk factors and management in patients with established cardiovascular disease in the Middle East. The Reduction of Atherothrombosis for Continued Health (REACH) registry provides a unique opportunity to characterise the risk-factor profile, treatment gaps and outcomes in patients with cardiovascular disease or cardiovascular disease risk factors in the Middle East. In the present analysis, we characterise the risk-factor profile, management patterns and treatment gaps among stable outpatients from the Middle East with cardiovascular disease or cardiovascular disease risk factors enrolled in the REACH registry.
METHODS The REACH registry is an international, prospective, observational study of stable outpatients with or at high risk for cardiovascular disease.10 11 A detailed design and methodology have been previously published.10 12 Briefly, consecutive eligible outpatients aged 45 or older with established coronary artery disease, cerebrovascular disease or peripheral arterial disease, or with at least three atherosclerotic risk factors were enrolled in 2004. Ethics committee approval was obtained at each participating institution, and each patient gave written informed consent to participate in the registry. The diagnosis of coronary artery disease required at least one of the following: history of stable or unstable angina with documented coronary artery disease, prior percutaneous coronary intervention or coronary artery bypass graft surgery, or previous myocardial infarction. Documented cerebrovascular 77
Original research Table 1 Baseline demographics of Middle Eastern patients in the Reduction of Atherothrombosis for Continued Health registry Age Male Diabetes mellitus Hypertension Hypercholesterolaemia Obesity Body mass index (
Prevalence and treatment of cardiovascular risk factors in outpatients with atherothrombosis in the Middle East Alawi A Alsheikh-Ali,1,2 Wael A Al-Mahmeed,1 Avi Porath,3 Ismail Khalil,4 Hisham Mahmoud,5 Deepak L Bhatt,6 P Gabriel Steg,7 on behalf of the REACH Registry Investigators 1
Institute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates 2 Institute for Clinical Research and Health Policy Studies and Tufts University School of Medicine, Boston, Massachusetts, USA 3 Maccabi Healthcare Services, Tel-Aviv, Israel 4 Division of Vascular Surgery & Wound Care Center, Department of Surgery, American University of Beirut, Beirut, Lebanon 5 Medical Affairs, Sanofi-aventis Gulf Office, Dubai, United Arab Emirates 6 VA Boston Healthcare System and Brigham and Women’s Hospital, Boston, Massachusetts, USA 7 INSERM U-698, Universite´ Paris 7 and AP-HP, Paris, France Correspondence to Dr Alawi A Alsheikh-Ali, Institute of Cardiac Sciences, Sheikh Khalifa Medical City, PO Box 51900, Abu Dhabi, United Arab Emirates; [email protected] Accepted 11 July 2011
ABSTRACT Objective To characterise the risk-factor profile and treatment gaps among patients with, or at risk for, cardiovascular disease in the Middle East. Design Secondary analysis of a prospective observational study. Setting International multicentre study (Reduction of Atherothrombosis for Continued Health). Patients Stable outpatients with established cardiovascular disease or at least three risk factors for atherothrombosis. The present analysis was based on 840 patients from the Middle East. Intervention Observational study without a studyspecific intervention. Main outcome measures A treatment gap was defined as at least one of the following: current cigarette smoking, total cholesterol $200 mg/dl, serum glucose $126 mg/dl or blood pressure of $140/90. Results The majority of Middle Eastern patients had hypertension (80.2%), more than half had a history of diabetes mellitus (52.3%), and a third had hypercholesterolaemia (34.1%). There was a high prevalence of obesity (38.6%), and nearly half the patients were former or current smokers (46%). b-Blockers and angiotensin-converting enzyme inhibitors were the most commonly prescribed antihypertensives (61.1% and 57.5%, respectively). Antiplatelet therapy (most commonly aspirin) and lipid-lowering drugs (most commonly a statin) were used in most patients (90.7% and 85.2%, respectively). Three-quarters of the participants (75.6%) had at least one uncontrolled risk factor. Conclusion Patients with atherothrombosis in the Middle East have a high prevalence of risk factors including alarming rates of diabetes mellitus and obesity. At least one risk factor is uncontrolled in the majority of patients, presenting a pressing need for improving the care of such patients in the Middle East.
INTRODUCTION Cardiovascular disease is the leading cause of morbidity and mortality worldwide.1 2 Over the past half century, our understanding of the epidemiology of and risk factors for cardiovascular disease has led to the development of effective measures to combat the cardiovascular epidemic, and resulted in significant improvements in patient outcomes. A substantial proportion of that improvement in cardiovascular disease outcomes was driven by Heart Asia 2011:77e81. doi:10.1136/ha.2010.003145
implementation of primary and secondary preventive measures in stable outpatients. To date, the vast majority of the literature on patients with, or at high risk for, cardiovascular disease comes from predominantly Western populations in affluent/industrialised countries. NonWestern and mostly developing regions of the world contribute an increasingly greater share to the global burden of cardiovascular disease, yet are greatly under-represented in the literature.3 4 In the Middle East, there is growing recognition that cardiovascular disease and its associated risk factors represent a significant public-health challenge, with some Middle Eastern countries reporting some of the highest rates of diabetes and obesity worldwide.5e9 Nonetheless, relatively few data are available on risk factors and management in patients with established cardiovascular disease in the Middle East. The Reduction of Atherothrombosis for Continued Health (REACH) registry provides a unique opportunity to characterise the risk-factor profile, treatment gaps and outcomes in patients with cardiovascular disease or cardiovascular disease risk factors in the Middle East. In the present analysis, we characterise the risk-factor profile, management patterns and treatment gaps among stable outpatients from the Middle East with cardiovascular disease or cardiovascular disease risk factors enrolled in the REACH registry.
METHODS The REACH registry is an international, prospective, observational study of stable outpatients with or at high risk for cardiovascular disease.10 11 A detailed design and methodology have been previously published.10 12 Briefly, consecutive eligible outpatients aged 45 or older with established coronary artery disease, cerebrovascular disease or peripheral arterial disease, or with at least three atherosclerotic risk factors were enrolled in 2004. Ethics committee approval was obtained at each participating institution, and each patient gave written informed consent to participate in the registry. The diagnosis of coronary artery disease required at least one of the following: history of stable or unstable angina with documented coronary artery disease, prior percutaneous coronary intervention or coronary artery bypass graft surgery, or previous myocardial infarction. Documented cerebrovascular 77
Original research Table 1 Baseline demographics of Middle Eastern patients in the Reduction of Atherothrombosis for Continued Health registry Age Male Diabetes mellitus Hypertension Hypercholesterolaemia Obesity Body mass index (
