Extent of Control of Cardiovascular Risk Factors and Adherence to Recommended Therapies in US Multiethnic Adults with Coronary Heart Disease

Abstract

Guidelines for cardiovascular risk factor control in people with coronary heart disease (CHD) focus on compliance with beta-adrenoceptor antagonists (beta-blockers), angiotensin receptor blockade (ACE inhibitors/angiotensin II receptor antagonists [angiotensin receptor blockers; ARBs]) [ACE/ARBs], and lipid-lowering agents, with goals for BP of <140/90 mmHg and low-density lipoprotein cholesterol (LDL-C) levels of <2.6 mmol/L (100 mg/dL). Most data derive from registries of hospitalized patients or are from clinical trials. Little data exist on goal attainment and adherence with therapy among CHD survivors of major US ethnic groups in the real-world setting. We assessed levels of cardiovascular risk factor control and adherence with recommended therapies among US CHD survivors. We identified 364 US adults (representing 12.8 million in the US with CHD) aged 18 years and over in the National Health and Nutrition Examination Survey 2005-6 with known CHD. We calculated proportions of patients who were receiving recommended treatments, and who achieved goal targets for BP, LDL-C levels, glycosylated hemoglobin (HbA(1c)), and nonsmoking status, and differences between actual and goal levels ('distance to goal'), stratified by sex and ethnicity. Overall, 58%, 38%, and 60% of CHD survivors were receiving beta-adrenoceptor antagonists, ACE/ARBs, and lipid-lowering medications, respectively (22% received all three). However, treatment rates for beta-adrenoceptor antagonists and lipid-lowering agents were lower (p < 0.05 to p < 0.01) in Hispanics (36% and 27%, respectively) and non-Hispanic Blacks (47% and 42%, respectively) than in non-Hispanic Whites. Moreover, lipid-lowering treatment rates were lower in females (50%) than in males (67%) [p < 0.01]. Overall, 78% were nonsmokers while 68% achieved goal levels for BP, 57% for LDL-C levels, and, if diabetic, 67% for HbA(1c). Only 12% met all four goals. Non-Hispanic Whites had the lowest SBP and DBP as well as HbA(1c) (p < 0.05 to p < 0.01 across ethnicity). In those who did not achieve goal levels, distance to goal averaged 1.0 mmol/L (37.0 mg/dL) for LDL-C levels, 15.6 mmHg for SBP, and 1.3% for HbA(1c). Despite clear treatment guidelines, we show that many US adults with CHD, especially Hispanics and non-Hispanic Blacks, are neither receiving recommended treatments nor adequately treated in terms of BP, LDL-C levels, and HbA(1c). Greater efforts by healthcare systems to disseminate and implement guidelines are needed.