Angina in patients with a previous heart attack is link with a poor outcome in patients with stable coronary artery disease, according to late breaking results from the CLARIFY study present in a Hot Line Session today at ESC Congress 2019 together with the World Congress of Cardiology and publish in the European Heart Journal.
The five-year results of this large registry also found that although the use of evidence base prevention medications was good, less than 10% of patients achieved the most recent recommend targets for blood pressure and cholesterol control. “They estimate that in Europe, around 22 million people have stable coronary artery disease,” said first author Dr. Emmanuel Sorbets of Hospital Avicenne of Bobigny, France. “The clinical profile and management of these patients has change over the last 25 years and there is little information about prognosis.”
Experience heart attack
CLARIFY was an observational and longitudinal study perform at 394 centres in 45 countries across five continents. (3,4) In 2009 to 2010, a total of 32,703 patients with stable coronary artery disease were enrolled. Stable coronary artery disease was define as having at least one of the following: previous myocardial infarction or revascularisation more than three months ago, proven symptomatic myocardial ischaemia, and angiographic coronary stenosis greater than 50%. Patients were followed-up once a year for five years.
The five-year rate of the composite primary outcome of cardiovascular death or myocardial infarction was 8.0%. Event rates range from 5.5% in Asia to 10.6% in Central/South America. In patients who had experience a previous heart attack; so those with angina had a significantly greater likelihood of the primary outcome (11.8%) compare to those without angina (8.2%). But in patients without a previous heart attack; event rates were lower and similar regardless of the presence of angina (6.3% with angina versus 6.4% without).
Dr. Sorbets said: “CLARIFY confirms that patients with prior myocardial infarction are at higher risk than those without. There has always been uncertainty about the effect of angina on cardiovascular outcomes. We show for the first time that angina worsens prognosis only in patients with a previous myocardial infarction. This is an easily identifiable high-risk subset that should be target for more intensive preventive treatment.”
Recommended blood pressure
Most patients receive prevention therapies regardless of their clinical profile and the geographical area in which they lived. However, few met the most recent recommend blood pressure and low density lipoprotein (LDL) cholesterol targets. Only 7.4% achieve both goals. “A potential explanation for the mismatch between treatment and attaining targets is that full doses may not be prescribe,” said Dr. Sorbets. “A previous analysis of CLARIFY show that just 13.3% of patients receive the full dose of beta blockers.
They did not collect dose information on the other therapies. Another likely possibility is that patients did not take their pills.” Some 12.5% of patients were current smokers. “The rate of smoking was relatively low; give that an earlier analysis find that 46.5% of participants were former smokers,” said Dr. Sorbets. “Nevertheless, smoking is relate to worse outcomes; so they need to keep encouraging patients to quit.”
Regarding what can be done to help stable coronary artery disease patients meet blood pressure and cholesterol targets, Dr. Sorbets said: “Doctors should prescribe full doses of preventive medications, particularly in those with angina and prior myocardial infarction, who have the worst prognosis. This group will benefit from careful management of their risk factors. They also need better ways to help patients consistently take their medications and to assess their adherence.”