Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: REACH Registry: An International Pandemic of Cardiovascular Disease
Event: ESC Congress 2010
Topic(s): PreventionVascular
Presenter: Deepak L. Bhatt, MD, FACC
Writer(s):
Date Posted: 08/30/2010


New analysis of 4-year event rates of The REACH Registry of stable outpatienst with known atherothrombotic disease or multiple risk factors found four simple criteria for identifying patients at higher risk for CV events: polyvascular disease, a recent ischemic event, a prior ischemic event at any time, and diabetes.

In addition, according to Dr. Deepak Bhatt, “For a variety of reasons, there’s still a lot of undertreatment of common risk factors, which are highly prevalent throughout the world.” Consequently, registry data show high rates of ischemic events in areas such as Japan, Taiwan, the Middle East, and Eastern Europe; places, he said, where widespread atherothrombotic disease was much less common just a generation ago.
Background

Atherothrombosis is the leading cause of CV morbidity and mortality, and the Reduction of Atherothrombosis for Continued Health (REACH) Registry is a single international database designed to characterize patterns in atherosclerosis risk factor profiles and treatment intensity of these patients. To this end, investigators followed 68,236 stable outpatients (typically treated in nonacademic centers) from 44 countries. All participants had coronary artery disease (CAD), cerebrovascular disease (CVD), peripheral arterial disease (PAD), or three or more risk factors for atherothrombosis.

The baseline publication reported that classic CV risk factors are consistent and common but largely undertreated and undercontrolled in most parts of the world.1 One-year results demonstrated a strong increased risk that was dependent on the number of arterial beds affected (so-called polyvascular disease):
5% event rate for patients with risk factors only
13% for patients with risk factors + 1 diseased vascular bed
22% for patients with risk factors + 2 diseased vascular beds
26% for patients with risk factors + 3 diseased vascular beds2

(Polyvascular disease refers to disease in different arterial beds and should not be confused with multivessel disease.)

Extrapolating from the REACH data, in the U.S. alone, up to 1.75 million CV events would be expected annually in patients with multiple arterial diseases. That’s a high event rate for a stable outpatient population treated with contemporary therapy. It was surprisingly high, too, for individuals without a history of CAD, CVD, or PAD but only multiple risk factors for these conditions (a 5% risk of hospitalization for atherothrombosis during 12 months of follow-up).
4-Year Results

The initial follow-up period was 2 years, but enrolling centers were invited to participate in a project extension lasting an additional 2 years. Follow-up data were available for 45,227 patients enrolled in 3,647 centers in 29 countries and will be published simultaneously in JAMA to coincide with Dr. Bhatt’s presentation at ESC Congress 2010.

Key results at 4 years:

The risk continuum for future CV events showed that patients with prior ischemic events at baseline were at greater risk than patients with stable atherosclerosis at baseline who were likewise at greater risk than individuals with risk factors only.

Polyvascular disease remained the strongest independent predictor of future CV events.

In patients with prior ischemic events, an event ≤1 year prior to enrollment was a strong predictor for CV events (vs. >1 year prior to enrollment).

Diabetes increased the risk of CV events in all populations but to a lesser extent than polyvascular disease or established atherosclerosis.
Diabetes – Not a CHD Equivalent?

One interesting observation from the REACH registry: diabetic patients without established atherothrombosis are at much lower risk than nondiabetic patients who did have atherothrombosis. This contradicts a classic study by Haffner et al. indicating that the presence of type 2 diabetes may confer the same degree of risk as preexisting coronary heart disease.3

“But the REACH dataset actually doesn’t show that,” said Dr. Bhatt. “I don’t want to downplay the importance of diabetes, but whether you actually have plaque in your arteries is a better predictor of whether you’re going to have a (cardiac event) than just having diabetes.”

Specifically, diabetic patients with risk factors only had a lower major adverse cardiac event rate than nondiabetic subjects or diabetic patients both with established atherothrombotic disease (2.2% vs 4.0% vs 6.0%, respectively; p <0.001 for the two comparisons).4
Take Home Messages
The REACH Registry analysis provides simple criteria for assessing risk for CV events in stable outpatients: polyvascular disease, a recent ischemic event, a prior ischemic event at any time, and diabetes.
Individuals with type 2 diabetes who pay careful attention to risk factor management have significantly less risk than a person with diabetes plus atherothrombotic disease.
The findings should help clinicians identify patients at very high risk of atherothrombotic events and adapt their treatment strategies accordingly.