This study sought to determine if an aggressive, focused low density lipoprotein cholesterol(LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance...This study sought to determine if an aggressive, focused low density lipoprotein cholesterol(LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance organization or Veterans Administration settings. Statin therapy benefits are well established. No prospective, randomized studies have tested strategies to optimize these benefits in a "real-world"setting. A total of 2,442 CHD patients with hyperlipidemia were randomized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average. Atorvastatingroup patients were titrated to LDL-C goals of< 80 mg/dl (2.1 mmol/l) or a maximum atorvastatin dose of 80 mg/day. Usual care patients received any treatment deemed appropriate by their regular physicians. End point assessments were complete in 958 atorvastatin-group and 941 usual-care patients. Partial assessments occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events, withdrawn consent, or follow-up loss. The primary efficacy parameter was time to first cardiovascular event. A total of 289(23.7%) patients in the atorvastatin group compared with 333(27.7%) patients in the usual care group experienced a primary outcome(hazard ratio, 0.83; 95%confidence interval 0.71 to 0.97, p=0.02). This reduction in morbidity was largely due to fewer non-fatal myocardial infarctions(4.3%vs. 7.7%, p=0.0002). Levels of LDL-C were reduced more(34.3%vs. 23.3%, p< 0.0001) and National Cholesterol Education Program goals(LDL-C< 100 mg/dl) more likely met at end-ofstudy visits(72.4%vs. 40.0%) in patients receiving atorvastatin compared with those receiving usual care. An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.展开更多
Beta-blocker therapy has been shown to benefit patients who have coronary artery disease and present with acute myocardial infarction(AMI) and/or congestive heart failure(HF). However, whether β-blocker therapy provi...Beta-blocker therapy has been shown to benefit patients who have coronary artery disease and present with acute myocardial infarction(AMI) and/or congestive heart failure(HF). However, whether β-blocker therapy provides a similar benefit in patients who have coronary artery disease but not AMI or HF is unknown. A population of 4,304 patients who did not have HF but did have angiographically confirmed coronary artery disease(≥1 stenosis of ≥70%) without AMI at hospital presentation was evaluated. Baseline demographics, cardiac risk factors, clinical presentation, therapeutic procedures, and discharge medications were recorded. Patients were followed for a mean of 3.0±1.9 years(range 1 month to 6.9 years) for outcomes of all-cause death or AMI. Patients’average age was 65±11 years and 77%were men. Overall, 10%died and 5%had a nonfatal AMI. Discharge β-blocker prescription was associated with an increased event-free AMI survival rate for all-cause death(no βblocker 88.3%, βblocker 94.5%, p< 0.001) and death/AMI(no βblocker 83.4%, βblocker 89.2%, p< 0.001) but not non-fatal AMI(no βblocker 93.6%,βblocker 94.1%, p=0.60). After adjustment for 16 covariates, including statin prescription, angiotensin-converting enzyme inhibitor prescription, and type of baseline therapy, the effect of βblockers on the combination end point of death/AMI was eliminated. However, the effect of βblockers on death remained(hazard ratio 0.66, 95%confidence interval 0.47 to 0.93, p=0.02). Thus, βblockers are clearly indicated for most patients who have HF or AMI, and our results suggest that patients who have coronary artery disease without these conditions have approximately the same protective benefit against death. No effect was observed on longitudinal incidence of AMI or the combination of death/nonfatal MI.展开更多
Context Few cardiovascular outcome data are available for blacks with hypertension treated with angiotensin-conver-ting enzyme(ACE) inhibitors or calcium channel blockers(CCBs). Objective To determine whether an ACE i...Context Few cardiovascular outcome data are available for blacks with hypertension treated with angiotensin-conver-ting enzyme(ACE) inhibitors or calcium channel blockers(CCBs). Objective To determine whether an ACE inhibitor or CCB is superior to a thiazide-type diuretic in reducing cardiovascular disease(CVD) incidence in racial subgroups. Design, Setting, and Participants Prespecified subgroup analysis of ALLHAT, a randomized, double-blind, active-controlled, clinical outcome trial conducted between February 1994 and March 2002 in 33 357 hypertensive US and Canadian patients aged 55 years or older(35%black) with at least 1 other cardiovascular risk factor. Interventions Antihypertensive regimens initiated with a CCB(amlodipine) or an ACE inhibitor(lisinopril) vs a thiazide-type diuretic(chlorthalidone). Other medications were added to achieve goal blood pressures(BPs) less than 140/90 mmHg. Main Outcome Measures The primary outcome was combined fatal coronary heart disease(CHD) or nonfatal myocardial infarction(MI), analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined CVD(CHD death, nonfatal MI, stroke, angina, coronary revascularization, heart failure HF , or peripheral vascular disease), and end-stage renal disease. Results No significant difference was found between treatment groups for the primary CHD outcome in either racial subgroup. For amlodipine vs chlorthalidone only, HF was the only prespecified clinical outcome that differed significantly(overall: relative risk RR , 1.37; 95%confidence interval CI , 1.24-1.51; blacks: RR, 1.46; 95%CI, 1.24-1.73; nonblacks: RR, 1.32; 95%CI, 1.17-1.49; P< .001 for each comparison) with no difference in treatment effects by race(P=.38 for interaction). For lisinopril vs chlorthalidone, results differed by race for systolic BP(greater decrease in blacks with chlorthalidone), stroke, and combined CVD outcomes(P< .001, P=.01, and P=.04, respectively, for interactions). In blacks and nonblacks, respectively, the RRs for stroke were 1.40(95%CI, 1.17-1.68) and 1.00(95%CI, 0.85-1.17) and for combined CVD were 1.19(95%CI, 1.09-1.30) and 1.06(95%CI, 1.00-1.13). For HF, the RRs were 1.30(95%CI, 1.10-1.54) and 1.13(95%CI, 1.00-1.28), with no significant interaction by race. Time-dependent BP adjustment did not significantly alter differences in outcome for lisinopril vs chlorthalidone in blacks. Conclusions In blacks and nonblack subgroups, rates were not lower in the amlodipine or lisinopril groups than in the chlorthalidone group for either the primary CHD or any other prespecified clinical outcome, and diuretic-based treatment resulted in the lowest risk of heart failure. While the improved outcomes with chlorthalidone were more pronounced for some outcomes in blacks than in nonblacks, thiazide-type diuretics remain the drugs of choice for initial therapy of hypertension in both black and nonblack hypertensive patients.展开更多
文摘This study sought to determine if an aggressive, focused low density lipoprotein cholesterol(LDL-C)-lowering strategy was superior to usual care for coronary heart disease (CHD) patients enrolled in health maintenance organization or Veterans Administration settings. Statin therapy benefits are well established. No prospective, randomized studies have tested strategies to optimize these benefits in a "real-world"setting. A total of 2,442 CHD patients with hyperlipidemia were randomized to either an aggressive treatment arm using atorvastatin or usual care and followed for 51.5 months on average. Atorvastatingroup patients were titrated to LDL-C goals of< 80 mg/dl (2.1 mmol/l) or a maximum atorvastatin dose of 80 mg/day. Usual care patients received any treatment deemed appropriate by their regular physicians. End point assessments were complete in 958 atorvastatin-group and 941 usual-care patients. Partial assessments occurred in 259 patients in the atorvastatin group and 284 patients in the usual care group who did not complete four years of study participation because of adverse events, withdrawn consent, or follow-up loss. The primary efficacy parameter was time to first cardiovascular event. A total of 289(23.7%) patients in the atorvastatin group compared with 333(27.7%) patients in the usual care group experienced a primary outcome(hazard ratio, 0.83; 95%confidence interval 0.71 to 0.97, p=0.02). This reduction in morbidity was largely due to fewer non-fatal myocardial infarctions(4.3%vs. 7.7%, p=0.0002). Levels of LDL-C were reduced more(34.3%vs. 23.3%, p< 0.0001) and National Cholesterol Education Program goals(LDL-C< 100 mg/dl) more likely met at end-ofstudy visits(72.4%vs. 40.0%) in patients receiving atorvastatin compared with those receiving usual care. An aggressive, focused statin therapy management strategy outperformed usual care in health maintenance organization and Veterans Administration clinic patients with CHD.
文摘Beta-blocker therapy has been shown to benefit patients who have coronary artery disease and present with acute myocardial infarction(AMI) and/or congestive heart failure(HF). However, whether β-blocker therapy provides a similar benefit in patients who have coronary artery disease but not AMI or HF is unknown. A population of 4,304 patients who did not have HF but did have angiographically confirmed coronary artery disease(≥1 stenosis of ≥70%) without AMI at hospital presentation was evaluated. Baseline demographics, cardiac risk factors, clinical presentation, therapeutic procedures, and discharge medications were recorded. Patients were followed for a mean of 3.0±1.9 years(range 1 month to 6.9 years) for outcomes of all-cause death or AMI. Patients’average age was 65±11 years and 77%were men. Overall, 10%died and 5%had a nonfatal AMI. Discharge β-blocker prescription was associated with an increased event-free AMI survival rate for all-cause death(no βblocker 88.3%, βblocker 94.5%, p< 0.001) and death/AMI(no βblocker 83.4%, βblocker 89.2%, p< 0.001) but not non-fatal AMI(no βblocker 93.6%,βblocker 94.1%, p=0.60). After adjustment for 16 covariates, including statin prescription, angiotensin-converting enzyme inhibitor prescription, and type of baseline therapy, the effect of βblockers on the combination end point of death/AMI was eliminated. However, the effect of βblockers on death remained(hazard ratio 0.66, 95%confidence interval 0.47 to 0.93, p=0.02). Thus, βblockers are clearly indicated for most patients who have HF or AMI, and our results suggest that patients who have coronary artery disease without these conditions have approximately the same protective benefit against death. No effect was observed on longitudinal incidence of AMI or the combination of death/nonfatal MI.
文摘Context Few cardiovascular outcome data are available for blacks with hypertension treated with angiotensin-conver-ting enzyme(ACE) inhibitors or calcium channel blockers(CCBs). Objective To determine whether an ACE inhibitor or CCB is superior to a thiazide-type diuretic in reducing cardiovascular disease(CVD) incidence in racial subgroups. Design, Setting, and Participants Prespecified subgroup analysis of ALLHAT, a randomized, double-blind, active-controlled, clinical outcome trial conducted between February 1994 and March 2002 in 33 357 hypertensive US and Canadian patients aged 55 years or older(35%black) with at least 1 other cardiovascular risk factor. Interventions Antihypertensive regimens initiated with a CCB(amlodipine) or an ACE inhibitor(lisinopril) vs a thiazide-type diuretic(chlorthalidone). Other medications were added to achieve goal blood pressures(BPs) less than 140/90 mmHg. Main Outcome Measures The primary outcome was combined fatal coronary heart disease(CHD) or nonfatal myocardial infarction(MI), analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined CVD(CHD death, nonfatal MI, stroke, angina, coronary revascularization, heart failure HF , or peripheral vascular disease), and end-stage renal disease. Results No significant difference was found between treatment groups for the primary CHD outcome in either racial subgroup. For amlodipine vs chlorthalidone only, HF was the only prespecified clinical outcome that differed significantly(overall: relative risk RR , 1.37; 95%confidence interval CI , 1.24-1.51; blacks: RR, 1.46; 95%CI, 1.24-1.73; nonblacks: RR, 1.32; 95%CI, 1.17-1.49; P< .001 for each comparison) with no difference in treatment effects by race(P=.38 for interaction). For lisinopril vs chlorthalidone, results differed by race for systolic BP(greater decrease in blacks with chlorthalidone), stroke, and combined CVD outcomes(P< .001, P=.01, and P=.04, respectively, for interactions). In blacks and nonblacks, respectively, the RRs for stroke were 1.40(95%CI, 1.17-1.68) and 1.00(95%CI, 0.85-1.17) and for combined CVD were 1.19(95%CI, 1.09-1.30) and 1.06(95%CI, 1.00-1.13). For HF, the RRs were 1.30(95%CI, 1.10-1.54) and 1.13(95%CI, 1.00-1.28), with no significant interaction by race. Time-dependent BP adjustment did not significantly alter differences in outcome for lisinopril vs chlorthalidone in blacks. Conclusions In blacks and nonblack subgroups, rates were not lower in the amlodipine or lisinopril groups than in the chlorthalidone group for either the primary CHD or any other prespecified clinical outcome, and diuretic-based treatment resulted in the lowest risk of heart failure. While the improved outcomes with chlorthalidone were more pronounced for some outcomes in blacks than in nonblacks, thiazide-type diuretics remain the drugs of choice for initial therapy of hypertension in both black and nonblack hypertensive patients.
