In Germany Diabetic Patients with Coronary Artery Disease are Treated More Intensively than Diabetic Patients with Other Manifestations of Atherothrombosis – Results from the REACH Registry

Abstract

Introduction: Atherothrombosis can present as coronary artery disease (CAD) cerebrovascular disease (CVD) and peripheral arterial disease (PAD). It is unknown whether diabetics with CAD differ from those with other manifestations of atherothrombosis such as CVD or PAD regarding clinical characteristics, biochemical parameters, or medications.

Material and Methods: The REACH (REduction of Atherothrombosis for Continued Health) registry evaluated 67 888 patients with established atherothrombosis or risk factors. Of 5 646 recruited German patients, 2 381 (42%) are diabetic. Of these 1 438 (60%) have CAD (either only CAD or in combination with CVD and/or PAD – CAD group) and 520 (22%) have other manifestations of atherothrombosis (either CVD or PAD or both – other manifestation group) and 18% have only risk factors. Differences between diabetics with CAD and diabetics with other manifestations of atherothrombosis were evaluated with multivariate models (79% male, 69±9 years, BMI 29±5 kg/m²) (SAS9.1).

Results: After correcting for age, sex and BMI, CAD patients receive (OR; 95% CI) more aspirin (1.5; 1.2–1.9; p=0.0002), statins (3.1; 2.6–3.7), beta-blockers (4.0; 3.8–4.8), diuretics (1.4; 1.2–1.6), ACE-inhibitors/ARBs (1.4; 1.2–1.7) and nitrates (8.8; 6.7–11.7) and significantly less often metformin (0.75; 0.61–0.93; p=0.01) with no differences concerning other antidiabetics. This resulted in significantly (p<0.05) lower blood-pressure (CAD 142/81 mmHg, other manifestations 145/82 mmHg) and LDL-cholesterol levels (CAD 108±37 mg/dl, other manifestations 123±37 mg/dl). Therefore more CAD patients reach LDL and blood-pressure-goals (CAD 47%/33%; other manifestations 30%/24%, respectively). Only few patients (CAD 7.1%, other manifestations 4.1%) reach all treatment goals. Furthermore, less CAD patients than patients with other manifestations of atherothrombosis are current smokers (11% vs. 22%).

Discussion: These data indicate considerable treatment differences between diabetics with CAD and those with other manifestations of atherothrombosis such as CVD or PAD. CAD patients are treated more intensively and therefore reach lower lipid and blood-pressure values.

Key words

diabetes - atherosclerosis - treatment goals - LDL-cholesterol - blood pressure

References

• 1 Amarenco P, Bogousslavsky J, Callahan A. et al . High-dose atorvastatin after stroke or transient ischemic attack.  N Engl J Med. 2006;  355 549-559
• 2 American Diabetes Association Executive Summary: Standards of Medical Care in Diabetes – 2008 . Diabetes Care. 2008;  31 S5
• 3 Baigent C, Keech A, Kearney PM. et al . Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90 056 participants in 14 randomised trials of statins.  Lancet. 2005;  366 1267-1278
• 4 Berthold HK, Gouni-Berthold I, Bestehorn K. et al . Kardiale Risikofaktoren bei Typ 2-Diabetikern in Deutschland – ein Versorgungsparadox.  Dtsch Ärzteblatt. 2007;  104 A861-A867
• 5 Bhatt DL, Steg PG, Ohman EM. et al . International Prevalence, Recognition, and Treatment of Cardiovascular Risk Factors in Outpatients With Atherothrombosis.  JAMA. 2006;  295 180-189
• 6 Bretzel RG, Landgraf R, Janka HU. et al . Hypertonie beim Diabetes mellitus.  Diabetologie. 2008;  3 S141-S142
• 7 Cholesterol Treatment Trialists’ (CTT) Collaborators, . Kearney PM,, Blackwell L, Collins R. et al . Efficacy of cholesterol-lowering therapy in 18 686 people with diabetes in 14 randomised trials of statins: a meta-analysis.  Lancet. 2008;  371 117-125
• 8 Gaede P, Lund-Andersen H, Parving H. et al . Effect oSf a Multifactorial Intervention on Mortality in Type 2 Diabetes.  N Engl J Med. 2008;  358 580-591
• 9 Gaede P, Vedel P, Larsen N. et al . Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes.  N Engl J Med. 2003;  ▪ 383-393
• 10 Grundy SM, Cleeman JI, Merz CN. et al . Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines.  Circulation. 2004;  110 227-239
• 11 Haffner SM. Coronary heart disease in patients with diabetes.  N Engl J Med. 2000;  342 1040-1042
• 12 Mazzone T, Chait A, Plutzky J. Cardiovascular disease risk in type 2 diabetes mellitus: insights from mechanistic studies.  Lancet. 2008;  371 1800-1809
• 13 National Cholesterol Education Program . Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel II).  Circulation. 1994;  89 1333-1445
• 14 Ohman EM, Bhatt DL, Steg PG. et al . The reduction of atherothrombosis for continued health (reach) registry: An international, prospective, observational investigation in subjects at risk for atherothrombotic events-study design.  Am Heart J. 2006;  151 (786) e781-e710
• 15 Paciaroni M, Hennerici M, Agnelli G. et al . Statins and stroke prevention.  Cerebrovasc Dis.. 2007;  24 170-182
• 16 Röther J, Alberts MJ, Touzè E. et al . Risk Factor Profile Management of Cerebrovascular Patients in the REACH Registry.  Cerebrovasc Dis. 2008;  25 366-374
• 17 Steg PG, Bhatt DL, Wilson PW. et al . One-year cardiovascular event rates in outpatients with atherothrombosis.  JAMA. 2007;  297 1197-1206
• 18 Steinberg BA, Steg PG, Bhatt DL. et al . Comparison of guideline-recommended therapies in patients with documented coronary artery disease having percutaneous coronary intervention versus coronary artery bypass grafting versus medical therapy only from the REACH International Registry.  Am J Cardiol. 2007;  99 1212-1215
• 19 Touzè E, Mas JL, Röther J. et al . Impact of carotid endarterectomy on medical secondary prevention after stroke of transient ischemic attack, Results from the REACH Registry.  Stroke. 2006;  27 2880-2885
• 20 Weckbach S, Findeisen HM, Schoenberg SO. et al . Systemic cardiovascular complications in patients with long-standing diabetes mellitus: comprehensive assessment with whole-body magnetic resonance imaging/magnetic resonance angiography.  Invest. Radiol.. 2009;  44 242-250
• 21 Zeymer U, Parhofer K, Senges J. et al . Ambulante Patienten mit atherothrombotischen Erkrankungen.  Dtsch Ärzteblatt. 2008;  105 769-775

Correspondence