International Journal of Cardiology 161 (2012) 18–24

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International Journal of Cardiology

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Secondary prevention in coronary artery disease. Achieved goals and possibilitiesfor improvements

Berglind Libungan a, Lillemor Stensdotter a, Agneta Hjalmarson a, Mona From Attebring b, Jonny Lindqvist a,Maria Bäck c, Johan Herlitz d,⁎a Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, 413 45 Göteborg, Swedenb School of Health and Caring Sciences, Linnaeus University, 351 95 Växjö, Swedenc Institute of Medicine, Physiotherapy Department, Sahlgrenska University Hospital, 413 45 Göteborg, Swedend Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital Göteborg and University College of Borås, Sweden

⁎ Corresponding author at: Institute of Medicine, DeparMedicine, SahlgrenskaUniversity Hospital, SE-413 45Göte7548.

E-mail address: johan.herlitz@gu.se (J. Herlitz).

0167-5273/$ – see front matter © 2011 Elsevier Irelanddoi:10.1016/j.ijcard.2011.04.025

a b s t r a c t

a r t i c l e i n f o

Article history:

Received 1 November 2010Received in revised form 20 April 2011Accepted 24 April 2011Available online 23 May 2011

Keywords:Coronary artery diseaseMyocardial infarctionAngina pectorisSecondary prevention

Aim: To describe presence of risk indicators of recurrence 6 months after hospitalisation due to coronaryartery disease at a university clinic.Methods: The presence of risk indicators, including tobacco use, lipid levels, blood pressure andglucometabolic status, including 24-hour blood pressure monitoring and an oral glucose-tolerance test,was analysed.Results: Of 1465 patients who were screened, 402 took part in the survey (50% previous myocardial infarctionand 50% angina pectoris). Mean age was 64 years (range 40–85 years) and 23% were women. Presentmedications were: lipid lowering drugs (statins; 94%), beta-blockers (85%), aspirin or warfarin (100%) andACE-inhibitors or angiotensin II blockers (66%).Values above target levels recommended in guidelines were: a) low density lipoprotein (LDL) in 40%; b)mean

blood pressure (day or night) in 38% and c) smoking in 13%. Of all patients, 66% had at least one risk factor(LDL or blood pressure above target levels or current smoking).An abnormal glucose-tolerance test was found in 59% of patients without known diabetes. If no history ofdiabetes, 85% had either LDL or blood pressure above target levels, current smoking or an abnormalglucose-tolerance test. However, with treatment intensification to patients with elevated risk factors 56%reached target levels for blood pressure and 79% reached target levels for LDL.Conclusion: Six months after hospitalisation due to coronary artery disease, despite the high use of medicationaimed at prophylaxis against recurrence, the majority were either above target levels for LDL or bloodpressure or continued to smoke.

© 2011 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

Coronary heart disease (CHD) is the primary cause of death in thedeveloped countries. Despite an improved prognosis probably due todecline in certain risk factors, early revascularisation and improveddrug therapy, the burden still remains high. Most probably this is dueto an ageing population. Patients with known coronary heart diseaserun the highest risk of subsequent events, with around 20% running a10-year risk [1]. These patients with prior disease should be amongstthe top priority for prevention. Risk reduction in those patients withknown CHD is referred to as secondary prevention.

The INTERHEART study [2] is a large, international, standardisedcase-control study, designed to assess the importance of risk factors for

tment of Molecular and Clinicalborg, Sweden. Tel.:+4631342

Ltd. All rights reserved.

coronary artery disease. A very high percentage (90% for men, 94% forwomen) of population-attributable risk in this study was accounted forby easily measured and potentially modifiable risk factors. The mostimportant risk factors identified in the study were high lipid levels (OR3.2), smoking (OR 2.9), diabetes (OR 2.4) and hypertension (OR 1.9).

Secondary prevention measures are effective in reducing coronarymortality and morbidity [3]. They include lifestyle changes (dietarymodification, smoking cessation and weight reduction) and prophylac-tic drug therapy (beta-blockers, ACE inhibitors, anti-platelet agents andlipid lowering therapy) [4]. Secondary prevention measures have beenperformed and showed that a large percentage of patients withcoronary artery disease do not reach target levels [5].

Prophylactic drug therapy, for example, is underused, despite thefact that the medications are well tolerated and current publishedguidelines are available [6]. Failure to achieve treatment goals has beenrelated to poor patient risk factor recognition [7] and non-compliance[8], physician non-adherence and co-morbidity resulting in therapymodification.

19B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

The primary objective was to describe the secondary preventionmeasures at a university clinic in Gothenburg, Sweden, for a pop-ulation with unstable and stable coronary artery disease. A secondaryobjective was to describe the possibilities to improve some of thesemeasures.

2. Patients and methods

2.1. Target population

Patients who were hospitalised at Sahlgrenska UniversityHospital/Sahlgrenska with a main diagnosis of coronary artery disease(i.e. myocardial infarction or angina pectoris) during the time period 1Oct 2007–1Oct 2009. Sahlgrenska has a catchment area of 250 thousandinhabitants.

Coronary artery disease was diagnosed with coronary angiographyeither prior to or at the time of hospitalisation.

2.2. Inclusion criteria

All patients who fulfilled the criteria stated above.

2.3. Exclusion criteria (Table 1)

1) High age in combination with severe co-morbidity (there was nospecific upper age limit. Thus the decision of exclusion was de-cided according to age in combination with comorbidity).

2) Unwillingness to participate.3) Other reasons (see Table 1).

2.4. Practical performance

Patients were approached by a study nurse via a telephone callabout 6 months (range 3–10 months) after hospital discharge. Withinthe next few days following the call, patients were investigated withregard to blood sampling, blood pressure monitoring and a detailedhistory of smoking.

2.5. Measurements and definition

2.5.1. Blood pressure at restBlood pressure at rest was measured in both arms while sitting,

preceded by a 5-minute rest without talking. The highest value wasrecorded.

Table 1Inclusion and exclusion.

n %

Patients evaluated 1465 100Patients included 402 27Patients excluded 1063 73Reason for exclusiona

Delayed evaluation 553 38Age+co-morbidity 213 15No contact by telephone 157 11Unwillingness 65 4Language problem 62 4Psychiatric disease 11 0.8Difficulties due to work 10 0.7Positive but did not come 9 0.6Social problems 8 0.5Hospitalised 12 0.8Neurological defect 5 0.3Living outside Gothenburg 4 0.3Living outside Sweden 2 0.1Protected ID 2 0.1Other 2 0.1

a There could be more than one exclusion criterion.

2.5.2. Twenty-four hour blood pressure recordingSpacelabs equipment was used [9]. Blood pressure was recorded

every 20 min between 6 am and 10 pm and once an hour between10 pm and 6 am. Mean blood pressure: ≥140/90 mm Hg during thedaytime or ≥130/80 mm Hg during the night were defined as highblood pressure. In diabetics, a stricter limit of≥130/80 mmHg duringthe daytime and ≥120/70 mm Hg at night was defined as high bloodpressure.

2.5.3. Oral glucose tolerance testHemocue Glucose 201+ was used for analysis [10]. A blood

glucose value 2 h after the oral intake of 75 g glucose of N7.8 mmol/lwas regarded as abnormal.

2.5.4. SmokingCurrent smoking was defined as daily or occasional smoking.

Ex-smoking status was confirmed by an expired carbon monoxidelevel of 10 ppm or less.

2.5.5. Smokeless tobacco (snus)The current use of snus was defined as the daily or occasional use

of snus. Claims to have stopped using snus were confirmed by acotinine value of less than 25 μg/l in blood.

2.6. Serum lipids (fasting)

2.6.1. CholesterolVenous blood was analysed with an enzymatic photometric

method, 505 nm at 37 °C. A value of ≥4.5 mmol/l was defined asabnormally high total cholesterol.

2.6.2. LDL cholesterolVenous bloodwas analysedwith an enzymatic photometricmethod,

600 nmat37 °C.A value of≥2.5 mmol/lwasdefinedasabnormally highLDL.

2.6.3. TriglyceridesVenous blood was analysed with an enzymatic photometric

method, 505 nm at 37 °C. A value of ≥1.7 mmol/l was defined ashigh serum triglyceride level.

2.6.4. Waist–hip ratioAn abnormal waist–hip ratio value was defined as ≥0.83 in

women and ≥0.9 in men.

2.7. Heart rate

The mean value of measurements every 20 min between 6 am and10 pm was recorded. A mean value of ≥80 beats per min was definedas an abnormal elevation.

2.8. Procedures after the evaluation

All patients with abnormal blood pressure values, abnormal LDLvalues or abnormal heart rates were offered a return visit to ourdepartment and were prescribed additional medication according toa pre-specified protocol. These patients were offered outpatientappointments until normalisation occurred.

2.9. Comparison with previous surveys

We compared the proportion of patients with LDL≤3.5 mmol/lamong those who were hospitalised due to coronary artery disease inprevious surveys in Gothenburg (the same criteria were applied as inthe present survey) and the present study cohort. With regard tomethodology, see Ref. [11].

Table 2A comparison between included and excluded patients.

Includedn=402

Excludedn=1063

p

Age (years) (1, 0)a

Mean±SD 64±9 68±12 b0.0001Gender (%) (1, 0)

Female 23 31 0.002Tobacco use

Smoking (0, 136) 23 25Snus – –

Medical history (%)Angina pectoris (0, 7) 50 47Diabetes (0, 3) 18 24 0.02Myocardial infarction (0, 8) 31 30Heart failure (0, 9) 7.5 11 0.05Hypertension (0, 6) 48 45

Type of CAD (0, 2) b0.0001STEMI 29 20Non-STEMI 18 30Unstable angina pectoris 36 18Stable angina pectoris 17 33

STEMI=ST-elevation myocardial infarction.a Number of patients with missing information.

20 B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

2.10. Statistical methods

In the evaluation of continuous variables, Pitman's test was used.In the evaluation of proportions, Fisher's exact test, a special form ofPitman's test, was used. Due to the large number of p-values that werecalculated, a p-value b0.01 was regarded as significant. Two-tailedtests were applied. In the tables, the results are presented with onedecimal if b10.

3. Results

In all, 1465 patients were screened for evaluation (i.e. were hos-pitalised for coronary artery disease during the time of the survey).

Among these patients, 402 (27%) took part in the final evaluation.These patients were evaluated with regard to potential risk indicators.The reasons for exclusion are given in Table 1. The high proportion(38%) excluded due to delayed evaluation was caused by the lack of

Table 3Age, gender and previous history.

n=402

All Women Men

Age (age) (mean±SD) 65±9.4 67±8.6 64±Gender (%)

Female 23Tobacco use

Smoking 23 17 24Snus 13 2.2 17

Previous history (%)Angina pectoris 50 50 50Diabetes 18 22 17Myocardial infarction 31 27 32Heart failure 7.5 9.7 6.8Hypertension 48 56 45Stroke 9.4 6.4 10Peripheral artery disease 7.5 9.7 6.8PCI 26 18 28CABG 10 7.5 11Atrial fibrillation 10 15 9.1Cancer 8.5 8.6 8.4Renal disease 2.2 3.2 1.6Other disease 18 29 15

Information available in all patients.PCI=Percutaneous Coronary Intervention.

a p-values noted if b0.10.

organisational capacity within the hospital to call all patients within6 months after hospitalization i.e. logistical problems.

3.1. A comparison between included and excluded patients (Table 2)

The included patients were 4 years younger and there were fewerwomen compared with the excluded patients. In terms of previoushistory, there were no marked differences with the exception of alower prevalence of diabetes among the included patients. The type ofcoronary artery disease that caused hospitalisation differed.ST-elevationmyocardial infarction (STEMI) was therefore more frequentamong included patients and stable angina pectoris was more frequentamong excluded patients.

3.2. The study cohort

3.2.1. Age, gender and previous history (Table 3)The mean age was 65 years. About a quarter were women. The age

range in women was 43–84 years and in men 30–84 years. The ma-jority had symptoms of previous coronary artery disease prior to theevent. About half had a history of hypertension and half had a historyof angina pectoris. Previous heart failure, peripheral artery diseaseand atrial fibrillation were more frequent in the elderly. On the otherhand, a history of smoking was more frequent in younger patients.

3.2.2. Type of CAD and complications in hospital (Table 4)About half the patients had a diagnosis of acute myocardial in-

farction and half had a diagnosis of angina pectoris. About 20% hadsome complication of which atrial fibrillation was most frequent.

A coronary angiogram while in hospital was performed in themajority of patients, more frequently among thosewhowere less than65 years of age.

3.2.3. On chronic medication at screening (Table 5)Nearly all the patients were on either aspirin or warfarin and 94%

were on lipid-lowering drugs. The latter were more frequently usedamong patients below 65 years of age. The majority were onbeta-blockers and two thirds were on ACE inhibitors or angiotensinreceptor blockade. Only 1 in 5 patients was on clopidogrel.

pa Age (years) p

≤65 N65

9.4 0.002

18 29

30 14 b0.0001b0.0001 19 7.3 b0.0001

46 5418 1930 334.3 11 0.01

0.08 44 528.6 102.9 12 b0.0001

0.08 24 278.6 125.7 16 b0.00016.2 112.9 1.0

0.004 15 22 0.09

Table 4Type of coronary artery disease and complications while in hospital.

All Women Men pa Age (years) p

≤65 N65

Type of coronary artery disease (%)STEMI 29 20 31 31 26Non-STEMI 18 23 16 16 19Unstable angina pectoris 36 46 33 36 36Stable angina pectoris 17 9.7 17 15 16

Complications and procedures while in hospital (%)Heart failure 11 7.5 12 8.1 14VF/VT 4.0 4.3 3.9 3.3 4.7Atrial fibrillation 13 12 14 9.5 18 0.02High degree AV block 1.5 0.0 2.0 1.4 1.6

Any procedures while in hospital (%)Coronary angiography 92 88 93 95 88 0.01PCI 65 64 65 69 60 0.08CABG 17 9.7 20 0.03 17 18

Information available in all patients.STEMI=ST-elevation myocardial infarction.VF=Ventricular fibrillation.VT=Ventricular tackycardia.PCI=Percutaneous Coronary Intervention.CABG=Coronary Artery Bypass Grafting.

a p-values noted if b0.10.

21B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

3.2.4. Presence of risk indicators (Table 6)Forty percent had LDL values above the recommended target

levels and 38% had blood pressure values above the target levels.Amongpatientswithoutdiabetes, 59%hadanabnormal glucose-tolerancetest, more frequently inwomen thanmen. A total of 12% had a highmeanheart rate during the day (≥80 beats per minute).

In the study population, 13% admitted smoking, while 10% usedsnus.

About 50% of the patients (113/197) who claimed to have stoppedsmoking, regardless of for how long, were tested for their CO value inexpired air. All CO values confirmed that they were not smoking.Cotinine values in blood were measured for 35 of the 43 patients whohad stopped using snus and were not smoking at the same time. Allvalues were under the cut-off limit for the use of nicotine.

Smoking and an elevated heart rate were more frequent inpatients ≤65 years of age.

Sixty-six percent had either LDL values above the recommendedtarget levels or mean blood pressure values above the target levels(day or night) or admitted smoking. Among patients with no historyof diabetes, 85% had any of the following: LDL values above target,blood pressure values above target, admitted smoking or an abnormalglucose-tolerance test.

When 3 further potential risk indicators (i.e. elevation of tri-glycerides, snus use and heart rate ≥80 beats per minute during theday) were added, the percentage of patients with any risk indicatorincreased to 75% for the total population (abnormal glucose-tolerance

Table 5On chronic medication at the time of evaluation.

All Women

MedicationAspirin 92 91Clopidogrel 20 15Warfarin 8.5 6.4Beta-blockers 86 87ACE inhibitors 48 38ACE inhibitors/angiotensin II-blockers 66 56Lipid-lowering drugs 94 91

Information available in all patients.ACE=Angiotensin Converting Enzyme.

a p-values noted if b0.10.

test not included) and to 89% among patients with no diabetes(abnormal glucose-tolerance test included).

3.2.5. ObesityThe waist–hip ratio was evaluated in all patients and was found to

be elevated in 75% (71% for women and 77% for men; NS).

3.3. Association between blood-pressure measurements according tooffice- and 24 h-measurements

Among patients with elevatedmean 24 h blood pressure accordingto given criteria 85% had a blood pressure more or equal to140/90 mm Hg (≥130/90 mm Hg in diabetes) at the screening officeregistration.

Among the patients who did not have elevated mean blood pres-sure according to given criteria 42% had an elevated blood pressure(criteria as above) at the office registration. Thus overall 60% of allpatients had an elevated blood pressure at the office registration.

3.4. Possibility to normalise elevated blood pressure, lipid levels andheart rate with treatment modification

Among patients with elevated blood pressure at 24 h measure-ment according to given criteria 93% accepted further treatmentmodification. Among them 56% reached blood pressure values at finaloffice registration below 140/90 mm Hg (below 130/90 mm Hg if

Men pa Age (years) p

≤65 N65

92 93 9121 21 189.1 5.2 12 0.02

85 85 8652 0.02 44 5370 0.02 65 6895 98 90 0.002

Table 6Presence of risk indicators at the time of evaluation.

All Women Men p AGE (years) p

≤65 N65

LDL≥2.5 mmol/l (394) 40 42 39 40 40OGTT≥7.8 mmol/l (319) 59 78 54 b0.0001 54 64 0.07Smoking (n=402) 13 14 13 18 8.8 0.01Snuff use (402) 9.7 2.2 12 0.004 13 6.2 0.03Elevated blood pressure during the day (n=401) 29 27 29 28 30Elevated blood pressure during the night (n=396) 27 27 27 27 28Elevated blood pressure day or night (n=399) 38 37 38 36 39Heart rate≥80 beats per min during the day (n=401) 12 12 12 16 7.3 0.01

Any risk indicators1) LDL or blood pressure above target levels or current smoking(all patients n=386)

66 69 66 68 64

2) LDL or blood pressure above target levels or current smoking orabnormal OGGT (no previous diabetes; n=310)

85 90 83 82 88

3) LDL or blood pressure above target levels or current smoking orsnuff use or heart rate≥80 beats per min or elevated triglycerides(all patients; n 395)

75 78 75 78 72

4) LDL or blood pressure above target levels or current smoking orsnuff use or heart rate≥80 beats per min or elevated triglyceridesor abnormal OGGT (no previous diabetes; n=323)

89 92 88 88 90

LDL=Low Density Lipoprotein.OGTT=Oral Glucose Tolerance Test.

22 B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

diabetes) requiring a mean of 2 further visits (range 1–7) and theaddition of 1 or 2 further medications (mostly a calcium channelblocker).

Amongpatientswithelevatedblood lipids according togiven criteria97% accepted further treatmentmodification. Among them79% reachedLDL values below2.5 mmol/l, requiring amean of 2 further visits (range1–7). Mostly an increase in statin dose or change in type of statin(mostly from simvastatin to atorvastatin) was required.

Among patients with elevated heart rate 88% accepted furthertreatment modification. Among them 68% reached target levels (heartrate below 80 beats per minute) requiring a mean of 2 further visits(range 1–5). The treatment mostly included intensification of beta-blockade (either increasing dose or new treatment).

3.5. Changes in lipid levels over time

The proportion of patients hospitalised due to coronary arterydisease with LDL-cholesterol values ≤3.5 mmol/l increased in a20-year perspective from 15% in 1993 to 84% in the present survey.

4. Discussion

4.1. Risk factors

In this study, we have demonstrated a high prevalence of mod-ifiable risk factors in patients with known coronary artery disease. Thestudy is unique since we analysed blood pressure and heart rate over24 h and related our findings to office blood pressure. We also val-idated smoking habits with biochemical markers. Finally we evalu-ated the possibility to quickly treat blood pressure, lipid levels andheart rate in order to reach target levels.

In a large European Survey (EUROASPIRE III) [12] from 2006–2007,a total of 8966 patients with established CHD were interviewed and17% smoked cigarettes, 35% were obese, 56% had elevated bloodpressure, 51% had high cholesterol and 25% had self-reported diabetes.

Our results show a lower rate of cigarette smoking (13%) com-pared with the EUROASPIRE III survey. However, this survey onlystudied patients below the age of 70 years, which might explain smalldifferences. Another question is whether we can trust the patients'reported use of tobacco. Almost all the patients who had stopped

using snus were tested with the biochemical marker cotinine and hada value that confirmed their self-report. Even patients who weretested for stopping smoking had CO values in expired air that vali-dated their reports. However only 57% of the ex-smokers were tested.In a previous study from our clinic [13], 6.5% of patients claiming tohave stopped smoking had a biochemical marker that contradictedtheir self-report. This means that the figures for smoking could besomewhat higher.

Most of the past studies of secondary prevention have relied onisolated blood pressure (BP) measurements, which could result in anoverestimation of patients with high BP due to white coat hyperten-sion [14]. This was also found in our study.

In the Heart Outcomes Prevention Evaluation Study, a smallsub-study [15] showed lower night-time BP values recorded byambulatory monitoring compared with point clinic measurements.

In this study, we used ambulatory blood pressure monitoring forthe evaluation of BP, which would exclude white coat hypertensionpatients. Despite this, we found that a high percentage of the patients(38%) still had poorly controlled blood pressure requiring theintensification of anti-hypertensive drug therapy or further lifestylechanges. This turned out to be an 18% lower percentage than in theEUROASPIRE III study and 22% lower than the office registered bloodpressure in our own study.

Major trials have shown that simvastatin and pravastatin reducecoronary mortality and morbidity [16]. The joint European Societiesrecommend goals of total cholesterol b4.5 mmol/l and LDL cholesterolb2.5 mmol/l for patients with coronary artery disease. Nearly all thepatients (94%)were on lipid-lowering drugs, but only 60% reached thegoal of LDL cholesterol b2.5 mmol/l. This illustrates even further poorphysician compliance with guidelines and the fact that some patientsmight need more intensive lipid-lowering statin treatment [17] or theaddition of another lipid-lowering agent to reach this goal.

In order to determine the occurrence of abnormal glucometabo-lism amongst the study population an oral glucose tolerance test waspreformed. Progression to type 2 diabetes is high amongst those witha abnormal OGTT, which also has been shown to be associated with aworse prognosis [18,19]. We found the majority (59%) of the patientswithout prior diabetes had an abnormal glucose-tolerance test. Thesame conclusion has been drawn by Bartnik et al. [20], where patientswith coronary heart disease underwent an OGTT and 58% had

23B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

abnormal glucose regulation (22% newly detected diabetes and 36%impaired glucose regulation). This means that abnormal glucoseregulation is more common than normal glucose regulation in pa-tients with coronary artery disease.

The percentage of patients with already known diabetes at en-rolment was 18%, which is the same percentage as in the EUROASPIRE Istudy [21]. Studies have shown that the population of diabetes patientsis increasing, whichwould lead to a higher percentage of diabetics withCAD in the near future. The reason for the increased prevalence andincidence of diabetes is thought to be higher age and the growingobesity problem in the western world [22].

When faced with this clinical problem of impaired glucose tol-erance in a patient with coronary artery disease, the patient should beadvised to make lifestyle changes, while aggressively treating highblood pressure and hyperlipidemia. Patients with diabetes havestricter goals relating to BP and lipid levels in the ESC guidelines.Lifestyle changes would include weight loss and dietary modificationto prevent further progression to overt diabetes. Those who receive adiagnosis of diabetes, in addition to lifestyle modification, would needtreatment to lower their blood glucose levels, aiming at normalisation,in order to prevent the continued progression of atherosclerosis [23].Due to high prevalence of abnormal glucometabolism and obesityamongst patients with coronary artery disease optimizing diet andexercise should be stressed in the patient contact.

Increased heart rate has been recognised in recent years as a riskfactor for cardiovascular disease. The potential pathophysiologicalmechanisms are increased oxygen consumption, sympathetic over-activity and even a direct role in atherosclerosis and plaque rupture. Inthe Göteborg Primary Prevention Trial [24], 7455 patients werefollowed for a mean of 12 years. The rate of death from cardiovasculardisease and total mortality increased with higher heart rate.

The clinical utility has been limited due to non-consensus relatingto the precise cut-off for the upper limit of normal resting heart rate.In most studies, the lower limit of top heart rate is between 80–90 beats per minute. In this study, we chose 80 beats per min andfound that 12% had a high resting heart rate. The therapeutic responsemay be to increase beta-blockade therapy in these patients whileavoiding symptomatic bradycardia or heart block.

Hip–waist ratio is a marker of abdominal obesity. In our study, themajority of patients had abdominal obesity, which has been found tohave a significant and graded association with the risk of myocardialinfarction [25].

Themajority of patients (85%) do not reach guideline target goals forimportant cardiac risk factors (have hyperlipidemia, high bloodpressure, positive OGTT or are currently smoking), despite therapyand clinical advice at a 6-month follow-up visit. These patients requiresubsequent clinical visits for therapy intensification and lifestyleconsultation.

4.2. Medication

All the patients in the study were on either ASA or warfarin, whichis a higher rate than in previous studies [12].

Only a small percentage (20%) of patientswas still on clopidogrel atthe time of evaluation, despite the fact that 65% underwent a per-cutaneous coronary intervention. This is probably due to the fact that,at that time, the current clinical practice was 3 months of treatmentafter coronary intervention, so many patients would already havecompleted the clopidogrel treatment that was recommended.

A large percentage of patients (86%) were already on beta-blockers,but medication that blocks the angiotensin-renin system (ACEI/ARB)was underused (66%). In addition to pure anti-hypertensive character-istics, these two drug classes (beta-blockers and ACEI/ARB) have animportant role to play in preventing future cardiovascular mortalityand morbidity [26].

5. Possibility to normalize elevated blood pressure, lipids andheart rate

Our data suggest that it is possible to normalize 80% of patientswith elevated lipids and more than 50% of patients with bloodpressure or heart rate elevation with treatment modification.

5.1. Limitations

Only 27% of the patients who were screened actually participatedin the survey. There is no question that those people with a greaterinterest in their own health would be more willing to participate inthis kind of survey. Perhaps even more compellingly, those who arenot willing to change their lifestyle could decide to avoid this kind ofsurvey. Patients who presented with STEMI were more likely toparticipate than those with stable angina. This could lead to a sam-pling bias.

We decided not to include patients with high age in combinationwith significant co-morbidity, which most likely resulted in ahealthier study population of patients with coronary artery disease.Thus, there was no upper age limit and the age was judged in com-bination with co-morbidity.

Although itwas our intention to evaluate all patients in the hospitalfor inclusion it is possible that a fraction was omitted simply due tologistical problems. Despite this limitation our results are well in linewith findings in an overall Swedish perspective [27].

In this study, if the patient said he/she was on medication, webelieved it. However, evidence shows that many patients actually donot take the prescribed medicines [28] and this problem can bebypassed using pharmacy-derived medication lists to find out howcompliant the patient is.

6. Conclusions

Secondary prevention is important in order to fight the furtherprogression of atherosclerotic disease and reduce mortality in coronaryartery disease. The majority of patients do not achieve the guidelinetarget goals and further intensification of therapy is indicated in order toreach them.

In many regards the results from this study is similar to largermulticenter studies (as the EUROASPIRE) but in this study the patientsunderwent additional evaluation tests such as ambulatory BP, am-bulatory heart rate measurements and did an oral glucose tolerancetest. Even with ambulatory BP measurements, nearly 40% of patientsdo not reach the target goals. The proportion of patients who reachedBP target levels after treatment modification is most likely under-estimated since we used office registration for analysis (includingwhite coat hypertension).

High heart rate was found amongst 12% of those with coronaryartery disease, who could benefit of increased beta-blockade in orderto decrease oxygen consumption.

Abnormal glucose regulation is found in the majority of patientswith coronary artery disease, so advice such as dietary modificationand weight loss should be included in follow-up clinical visits.

Most likely target levels can be achieved in a large proportion ofpatients with elevation of blood pressure, heart rate and lipid levels.

Conflict of interest

There are no conflicts of interest.

Acknowledgement

This study was supported by grants from Pfizer Pharmaceuticals.The authors of this manuscript have certified that they comply withthe Principles of Ethical Publishing in the International Journal of

24 B. Libungan et al. / International Journal of Cardiology 161 (2012) 18–24

Cardiology. Shewan LG and Coats AJ. Ethical authorship and publish-ing. Int J Cardiol 2010;144: 1–2 [29].

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