Chronic kidney disease has a graded association with death and cardiovascular outcomes in stable coronary artery disease: an analysis of 21,911 patients from the CLARIFY registry

Chronic kidney disease (CKD) is associated with an increased cardiovascular risk in a broad spectrum of populations. However, the risk associated with a reduced estimated glomerular filtration rate (eGFR) in patients with stable coronary artery disease receiving standard care in the modern era, independently of baseline cardiovascular disease, risk factors, and comorbidities, remains unclear. We analyzed data from 21,911 patients with stable coronary artery disease, enrolled in 45 countries between November 2009 and July 2010 in the CLARIFY registry. Patients with abnormal renal function were older, with more comorbidities, and received slightly lower—although overall high—rates of evidence-based secondary prevention therapies than patients with normal renal function. The event rate of patients with CKD stage 3b or more (eGFR <45 mL/min/1.73 m2) was much higher than that associated with any comorbid condition. In a multivariable adjusted Cox proportional hazards model, lower eGFR was independently associated with a graded increased risk of cardiovascular mortality, with adjusted HRs (95% CI) of 0.98 (0.81–1.18), 1.31 (1.05–1.63), 1.77 (1.38–2.27), and 3.12 (2.25–4.33) for eGFR 60–89, 45–59, 30–44, and <30 mL/min/1.73 m2, compared with eGFR ≥90 mL/min/1.73 m2. A strong graded independent relationship exists between the degree of CKD and cardiovascular mortality in this large cohort of patients with chronic coronary artery disease, despite high rates of secondary prevention therapies. Among clinical risk factors and comorbid conditions, CKD stage 3b or more is associated with the highest cardiovascular mortality

Potential impact of the 2017 ACC/AHA guideline on high blood pressure in normotensive patients with stable coronary artery disease: insights from the CLARIFY registry

Aims: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) guideline on high blood pressure (BP) lowered the threshold defining hypertension and BP target in high-risk patients to 130/80 mmHg. Patients with coronary artery disease and systolic BP 130-139 mmHg or diastolic BP 80-89 mmHg should now receive medication to achieve this target. We aimed to investigate the relationship between BP and cardiovascular events in 'real-life' patients with coronary artery disease considered as having normal BP until the recent guideline. Methods and results: Data from 5956 patients with stable coronary artery disease, no history of hypertension or heart failure, and average BP <140/90 mmHg, enrolled in the CLARIFY registry (November 2009 to June 2010), were analysed. In a multivariable-adjusted Cox proportional hazards model, after a median follow-up of 5.0 years, diastolic BP 80-89 mmHg, but not systolic BP 130-139 mmHg, was associated with increased risk of the primary endpoint, a composite of cardiovascular death, myocardial infarction, or stroke (hazard ratio 2.15, 95% confidence interval 1.22-3.81 vs. 70-79 mmHg and 1.12, 0.64-1.97 vs. 120-129 mmHg). No significant increase in risk for the primary endpoint was observed for systolic BP <120 mmHg or diastolic BP <70 mmHg. Conclusion: In patients with stable coronary artery disease defined as having normal BP according to the 140/90 mmHg threshold, diastolic BP 80-89 mmHg was associated with increased cardiovascular risk, whereas systolic BP 130-139 mmHg was not, supporting the lower diastolic but not the lower systolic BP hypertension-defining threshold and treatment target in coronary artery disease. ClinicalTrials identifier: ISRCTN43070564

Management of coronary artery disease patients in Latvia compared with practice in Central-Eastern Europe and globally: Analysis of the CLARIFY registry

BACKGROUND AND OBJECTIVE: Management of outpatients with stable coronary artery disease (CAD) is important in secondary prevention. The objective was to describe differences in the characteristics of CAD patients in Latvia compared with other countries. MATERIALS AND METHODS: CLARIFY is an ongoing international, prospective, observational, longitudinal registry of outpatients with CAD. Data regarding treated outpatients with established CAD from the CLARIFY registry in Latvia (n=120) were compared with those from the rest of Central-Eastern Europe (CEE) (n=2888) and worldwide (n=33,163). RESULTS: Patients in Latvia had a larger waist circumference (101 [95-109] vs. 99 [91-106] in CEE, 96.5 [88-105]cm worldwide; P=0.023 and P<0.001, respectively) and higher blood pressure (systolic: 138.28±17.13 vs. 133.77±16.47 in CEE and 130.97±16.65mm Hg worldwide, P=0.003 and P<0.001; diastolic: 82.98±8.58 vs. 80.01±9.61 in CEE and 77.22±9.97mm Hg worldwide, P<0.001 and P<0.001, respectively). Body mass index in Latvia did not differ significantly from that in CEE (P=0.422), but was higher than worldwide (28.8 [26.2-32.0] vs. worldwide 27.3 [24.8-30.3]kg/m(2), P<0.001). The history of percutaneous coronary intervention was more frequent in Latvia (74.17% vs. 59.34% in CEE and 58.61% worldwide, P=0.001 and P<0.001, respectively). Latvian patients more frequently used aspirin (97.50% in Latvia vs. 89.75% in CEE and 87.64% worldwide, P=0.005 and P=0.001, respectively). CONCLUSIONS: Latvian CAD patients are well managed in terms of aspirin use and frequency of percutaneous coronary intervention. Control of obesity and high BP is poorer and needs further improvement

Częstotliwość rytmu serca i farmakoterapia beta-adrenolitykami u pacjentów ambulatoryjnych ze stabilną chorobą wieńcową: charakterystyka wyjściowa polskiej populacji rejestru CLARIFY

Background: Heart rate (HR) is an important risk factor in coronary artery disease (CAD). However, there is little contemporary data on HR and the use of HR-lowering medications, particularly beta-blockers, among patients with stable CAD inroutine clinical practice.Aim: To describe HR in the Polish population of the CLARIFY registry, overall and in relation to beta-blocker use, and to assessthe determinants of HR.Methods and results: CLARIFY is an international, prospective, observational, longitudinal registry of outpatients with stable CAD, defined as either prior myocardial infarction or revascularisation procedure, or evidence of coronary stenosis of at least 50%, orchest pain associated with proven myocardial ischaemia. A total of 33,438 patients from 45 countries in Europe, the Americas, Africa, the Middle East, and Asia/Pacific were enrolled between November 2009 and July 2010. In Poland, 1,004 patients were enrolled between February and June 2010, which was the largest population among countries from Eastern Europe. Most patients were men (72.8%). Mean ± standard deviation age was 62.1 ± 9.1 years. HR determined by pulse was 69.3 ± 9.4 bpm and by electrocardiogram was 68.2 ± 10.6 bpm. Beta-blockers were used in 89.9% of patients. Resting HR ≥ 70 bpm was noted in 49.3% of all patients and in 48.6% of patients on beta-blockers. Resting HR ≥ 70 bpm was significantly more frequent among younger patients, and in those with diabetes, those being treated for arterial hypertension, and who lacked regular physical activity. Patients with HR ≥ 70 bpm at rest had more frequent symptoms of angina and more frequently needed hospitalisation due to heart failure.Conclusions: Despite a very high rate of beta-blocker use, almost 50% of patients with stable CAD had a resting HR ≥ 70 bpm, which was associated with more frequent angina and ischaemia. Further HR lowering is possible in many patients with CAD. Whether or not this will improve symptoms and outcomes is under investigation.Wstęp: Częstotliwość rytmu serca (HR) jest ważnym czynnikiem ryzyka u pacjentów ze stabilną chorobą wieńcową (CAD). Wciąż mało jest aktualnych danych na temat HR i farmakoterapii za pomocą leków obniżających HR (w tym beta-adrenolityków) w codziennej praktyce klinicznej u pacjentów ze stabilną CAD.Cel: Celem niniejszego artykułu jest omówienie wyjściowej charakterystyki polskiej populacji rejestru CLARIFY, również w odniesieniu do leczenia beta-adrenolitykami oraz ocena czynników wpływających na HR.Metody i wyniki: CLARIFY to międzynarodowe, prospektywne badanie obserwacyjne dotyczące ambulatoryjnych pacjentów ze stabilną CAD. Kryteriami włączenia były: wywiad zawału serca, przebyte leczenie rewaskularyzacyjne, stwierdzenie w koronarografii co najmniej 50% zwężeń w tętnicach wieńcowych lub występowanie dolegliwości stenokardialnych z udowodnionym niedokrwieniem w testach prowokacyjnych. Pomiędzy listopadem 2009 r. a lipcem 2010 r. do badania włączono 33 438 pacjentów z 45 krajów Europy, Ameryki Północnej i Południowej, Afryki, Azji, Australii i Oceanii. W Polsce między lutym a czerwcem włączono 1004 osób, co stanowi największą grupę chorych wśród krajów tzw. Europy Wschodniej. W większości byli to mężczyźni (72,8%). Średni (± SD) wiek wynosił 62,1 ± 9,1 roku, średnia HR oceniana za pomocą fali tętna wynosiła 69,3 ± 9,4, a za pomocą elektrokardiogramu 68,2 ± 10,6 uderzeń na minutę. Beta-adrenolityki były stosowane u 89,9% pacjentów. Spoczynkową HR ≥ 70/min stwierdzono u 49,3% wszystkich chorych i u 48,6% pacjentów leczonych beta-adrenolitykami. Spoczynkowa HR ≥ 70/min istotnie częściej występowała u młodszych pacjentów, z cukrzycą, leczonym nadciśnieniem tętniczym i niestosujących regularnie wysiłku fizycznego. U chorych ze spoczynkową HR ≥ 70/min częściej występowały objawy dławicowe i częściej wymagali hospitalizacji z powodu niewydolności serca.Wnioski: Pomimo bardzo wysokiego odsetka pacjentów ze stabilną CAD leczonych beta-adrenolitykami nadal u niemal 50% osób spoczynkowa HR wynosi ≥ 70/min, co wiąże się z częstszym występowaniem objawów dławicowych i niedokrwieniem mięśnia sercowego. U wielu z tych chorych można w istotny sposób zwolnić spoczynkową HR. Odpowiedź na pytanie, czy takie postępowanie będzie się wiązało z poprawą rokowania i zmniejszeniem dolegliwości, wymaga przeprowadzenia dalszych badań.

Rationale, design, and baseline characteristics of the CLARIFY registry of outpatients with stable coronary artery disease

Background: Despite major advances in prevention and treatment, coronary artery disease (CAD) remains the leading cause of death worldwide. Whereas many sources of data are available on the epidemiology of acute coronary syndromes, fewer datasets reflect the contemporary management and outcomes of stable CAD patients. Hypothesis: A worldwide contemporary registry would improve our knowledge about stable CAD. The main objectives are to describe the demographics, clinical profile, contemporary management and outcomes of outpatients with stable CAD; to identify gaps between evidence and treatment; and to investigate long-term prognostic determinants. Methods: CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) is an ongoing international observational longitudinal registry. Stable CAD patients from 45 countries in Europe, Asia, America, Middle East, Australia and Africa were enrolled between November 2009 and June 2010. The inclusion criteria were previous myocardial infarction, evidence of coronary stenosis >50%, proven symptomatic myocardial ischemia or prior revascularization procedure. The main exclusion criteria were serious non-cardiovascular disease, conditions interfering with life expectancy or severe other cardiovascular disease (including advanced heart failure). Follow-up visits were planned annually for up to 5 years, interspersed with 6-month telephone calls. Results: Of the 32,703 patients enrolled, most (77.6%) were male, age (mean ± SD) was 64.2 ± 10.5 years, and 71.0% were receiving treatment for hypertension; mean ± SD resting heart rate was 68.2 ± 10.6 bpm. Patients were enrolled based on a history of myocardial infarction >3 months earlier (57.7%), having at least one stenosis >50% on coronary angiography (61.1%), proven symptomatic myocardial ischemia on non-invasive testing (23.1%), or history of percutaneous coronary intervention or coronary artery bypass graft (69.8%). Baseline characteristics were similar across the four subgroups identified by the four inclusion criteria. Conclusion: CLARIFY will provide a useful resource for understanding the current epidemiology of stable CAD

Motherhood and mothering The experience of three generations of Jamaican heritage women in Manchester

SIGLEAvailable from British Library Document Supply Centre- DSC:DXN059307 / BLDSC - British Library Document Supply CentreGBUnited Kingdo

Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: A prospective analysis of 22,272 patients

Purpose: To assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease