Missed opportunities for the secondary prevention of cardiovascular disease in CanadaPrévention secondaire des maladies cardiovasculaires au Canada : Occasions manquées pour la

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Background

Strong evidence supports the use of antithrombotic agents (antiplatelets or oral anticoagulants), statins and angiotensin-converting enzyme inhibitors in patients with atherosclerotic cardiovascular disease; beta-blockers are additionally indicated in patients with coronary artery disease.

Objectives

The investigators sought to determine the extent to which guideline-recommended treatments and target goals are adopted in ambulatory patients with cardiovascular disease in Canada.

Methods

Two large, prospective, community-based registries (the Vascular Protection Registry and the Guideline Oriented Approach to Lipid Lowering Registry) enrolled 9809 outpatients with coronary artery disease, cerebrovascular disease, peripheral vascular disease or multiple cardiovascular risk factors from primary care settings in nine provinces across Canada between 2001 and 2004. This analysis focused primarily on patients with cardiovascular disease (n=6296).

Results

At baseline, antithrombotics, statins and angiotensinconverting enzyme inhibitors were used in 92%, 80% and 57% of patients, respectively; beta-blockers were used in 59% of patients with coronary artery disease. The dosing of most drug therapies was suboptimal compared with guideline-recommended dosing derived from clinical trials. Treatment goals for cardiovascular risk factors were suboptimally attained: low-density lipoprotein cholesterol in 50% of patients, total to high-density lipoprotein cholesterol ratio in 51% of patients, systolic and diastolic blood pressure in 58% and 78% of patients, respectively, and waist circumference and body mass index in 45% and 19%, respectively.

Conclusions

These data suggest specific opportunities for improving the care of patients with cardiovascular disease in Canada. The focus must now shift from awareness of treatment gaps to implementation of effective solutions.

Historique

Des preuves irréfutables appuient l’utilisation des antithrombotiques (antiplaquettaires ou anticoagulants oraux), des statines et des inhibiteurs de l’enzyme de conversion de l’angiotensine chez les patients souffrant de maladie cardiovasculaire athéroscléreuse. Les bêtabloquants sont également indiqués chez les patients qui souffrent de maladie coronarienne.

Objectifs

Les investigateurs ont tenté de déterminer dans quelle mesure les traitements et objectifs émanant de lignes directrices sont appliqués chez les patients non hospitalisés atteints de maladie cardiovasculaire au Canada.

Méthodes

Deux grands registres prospectifs basés dans la communauté (le Vascular Protection Registry et le Guideline Oriented Approach to Lipid Lowering Registry) ont inscrit 9 809 patients non hospitalisés souffrant de coronaropathie, de maladie vasculaire cérébrale, de maladie vasculaire périphérique ou de facteurs de risque cardiovasculaires multiples, soignés en médecine de premier recours dans neuf provinces du Canada entre 2001 et 2004. Cette analyse s’est principalement attardée aux patients atteints de maladie cardiovasculaire (n = 6 296).

Résultats

Au départ, les antithrombotiques, les statines et les inhibiteurs de l’enzyme de conversion de l’angiotensine étaient utilisés chez 92%, 80% et 57% des patients, respectivement. Les bêtabloquants étaient utilisés chez 59% des patients atteints de coronaropathie. La posologie de la plupart des traitements médicamenteux était sous-optimale comparativement aux posologies préconisées dans les lignes directrices et déterminées à partir d’essais cliniques. Les objectifs thérapeutiques dans le cas des facteurs de risque cardiovasculaires ont également été plus ou moins atteints : cholestérol-LDL chez 50% des patients, rapport cholestérol total:cholestérol-HDL chez 51% des patients, tension artérielle systolique et diastolique chez 58% et 78% des patients, respectivement, et tour de taille et indice de masse corporelle, chez 45% et 19% des patients, respectivement.

Conclusions

Ces données illustrent les secteurs spécifiques où il y a lieu d’améliorer les soins aux patients atteints de maladie cardiovasculaire au Canada. Il faut maintenant dépasser le stade de la sensibilisation aux lacunes thérapeutiques pour appliquer des solutions efficaces.

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