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

Women and men with stable coronary artery disease have similar clinical outcomes: insights from the international prospective CLARIFY registry

<p>Aims Men and women differ in terms of presentation and management in coronary artery disease (CAD). Whether these differences translate into different clinical outcomes in stable CAD is unclear. We analysed data from the international prospective CLARIFY registry to compare cardiovascular clinical outcomes in men and women with stable CAD.</p> <p>Methods and results We analysed 1-year outcomes in 30 977 outpatients with stable CAD [23 975 (77.4%) men; 7002 (22.6%) women]. Women were older than men, more likely to have hypertension and diabetes, and less likely to exercise or smoke. They had more frequent angina, but were less likely to have undergone diagnostic non-invasive testing or coronary angiography. Women received less optimized treatment for stable CAD. One-year outcomes were similar for men and women for the composite of cardiovascular death, non-fatal myocardial infarction, or stroke [adjusted rates 1.7 vs. 1.8%, respectively, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.75–1.15]; all-cause death (adjusted 1.5 vs. 1.6%, OR: 0.91, 95% CI: 0.72–1.13); fatal or non-fatal myocardial infarction (adjusted 1.0 vs. 0.9%, OR: 0.81, 95 CI: 0.60–1.08); and cardiovascular death or non-fatal myocardial infarction (adjusted 1.4 vs. 1.4%, OR: 0.89, 95% CI: 0.70–1.12). Fewer women underwent revascularization (2.6 vs. 2.2%, OR: 0.77, 95% CI: 0.64–0.93), although appropriateness was not analysed.1522-9645</p> <p>Conclusion The risk profiles of women and men with stable CAD differ substantially. However, 1-year outcomes were similar. Fewer women underwent revascularization. Further research is needed to better understand gender determinants of outcome and devise strategies to minimize bias in the management and treatment of women.</p&gt

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.