The A-SACT (Achievement in Singapore of Cholesterol Targets) Study in Patients with Coronary Heart Disease
- 42 Downloads
Cardiovascular disease remains a leading cause of death worldwide, with hypercholesterolemia being a major risk factor. Evidence-based consensus guidelines have recommended consideration of increasingly stringent cholesterol-lowering goals, yet most patients do not meet these targets. Coronary heart disease (CHD) event and mortality rates and mean serum cholesterol levels have declined in Singapore in recent years; however, certain groups remain at elevated risk.
To determine (i) proportions of patients with CHD in Singapore who achieved goals for serum low-density lipoprotein-cholesterol (LDL-C); and (ii) factors influencing goal attainment.
A historical cohort study was conducted using records from the Singapore Cardiac Databank, a national registry of CHD patients. Serum LDL-C goal attainment was assessed in 5174 survivors of acute myocardial infarction or coronary revascularization (i.e. coronary artery bypass graft surgery or percutaneous coronary interventions), of whom 3811 (73.7%) were at very high risk.
At baseline, the mean patient age was 60.3 years, mean serum value of total cholesterol was 228 mg/dL, and mean LDL-C was 163mg/dL. Of all CHD patients, approximately 70% did not achieve a serum LDL-C target of <100mg/dL. Most patients receiving HMG-CoA reductase inhibitor (statin) regimens were treated initially with low- to medium-equipotency regimens and were never titrated to stronger regimens. The vast majority (∼94%) of patients at very high risk did not achieve the stringent serum LDL-C target of <70mg/dL. Patients receiving higher potency statins were significantly more likely to achieve LDL-C goals, whereas those with higher baseline LDL-C levels or Malaysian ethnicity were less likely to achieve LDL-C goals.
Most CHD patients in the large group of Singapore residents with CHD in the present study did not achieve recommended LDL-C targets. A more effective disease-management approach, including patient education concerning lifestyle modification (e.g. diet, physical activity), efforts to enhance medication adherence, and more effective, well tolerated therapies such as high-equipotency or high-dose statins and statin combination regimens, may be needed to improve achievement of consensus cholesterol targets. This is the first study of cholesterol goal attainment in a large group of Southeast Asians and serves as a baseline for future evaluations in Asian populations.
KeywordsCoronary Heart Disease Statin Coronary Heart Disease Patient Cholesterol Goal Enhance Medication Adherence
Assistance in manuscript preparation was provided by Stephen W. Gutkin, Rete Biomedical Communications Corp. (Ridgewood, NJ, USA). Med Data Analytics Inc. had access to the database on which this study report was based. Dr Binayak Deb assisted in acquiring, analyzing, and interpreting data.
Author contributions: Study concept: Kheng-Thye Ho; Study design: Dr Ho and all other authors; Acquisition of data: Dr Ho, Khong-Whee Chin, and Kheng-Siang Ng; Analysis and interpretation of data; all authors; Drafting of the manuscript: Dr Ho with editorial assistance from Stephen W. Gutkin; Critical revision of the manuscript for important intellectual content: all authors; Statistical analysis: Srinivasan Rajagopalan; Obtained funding: Dr Ho; Administrative, technical, and material support: Evo Alemao; Study supervision: Dr Ho. Financial support for the study was provided by a grant from MSP (Merck/Schering-Plough) Singapore Company, LLC.
Conflicts of interest are as follows: Khong-Whee Chin is an employee of Merck Research Laboratories, Merck and Co., Inc. Evo Alemao and Don Yin are employees of Merck and Co., Inc., and are Merck shareholders (stocks and stock options). Srinivasan Rajagopalan and Stephen W. Gutkin are paid consultants to Merck. Neither Kheng-Thye Ho nor Kheng-Siang Ng has any affiliation with the sponsor or any financial interests in this report.
- 1.World Health Organization. World health report 1999: making a difference [online]. Available from URL: http://www.who.int/whr/en/ [Accessed 2006 May 23].Google Scholar
- 2.World Health Organization. World health report 2003: shaping the future [online]. Available from URL: http://www.who.int/whr/en/ [Accessed 2006 Jan 29].Google Scholar
- 4.Stamler J, Wentworth D, Neaton JD. Is relationship between serum cholesterol and risk of premature death from coronary heart disease continuous and graded? Findings in 356,222 primary screenees of the Multiple Risk Factor Intervention Trial (MRFIT). JAMA 1986 Nov; 256(20): 2823–8.PubMedCrossRefGoogle Scholar
- 7.Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994 Nov; 344 (8934): 1383–9.Google Scholar
- 10.Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels: the Long-Term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. N Engl J Med 1998 Nov; 339 (19): 1349–57.Google Scholar
- 13.Colhoun HM, Betteridge DJ, Durrington PN, et al. Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 2004 Aug; 364(9435): 685–96.PubMedCrossRefGoogle Scholar
- 14.Sever PS, Dahlof B, Poulter NR, et al. Prevention of coronary and stroke events with atorvastatin in hypertensive patients who have average or lower-than-average cholesterol concentrations, in the Anglo-Scandinavian Cardiac Outcomes Trial-Lipid Lowering Arm (ASCOT-LLA): a multicentre randomised controlled trial. Lancet 2003 Apr; 361(9364): 1149–58.PubMedCrossRefGoogle Scholar
- 23.De Backer G, Ambrosioni E, Borch-Johnsen K, et al. European guidelines on cardiovascular disease prevention in clinical practice: Third Joint Task Force of European and other societies on cardiovascular disease prevention and clinical practice. Eur J Cardiovasc Prev Rehabil 2003; 10 Suppl. 1: S1–S78.CrossRefGoogle Scholar
- 24.International Atherosclerosis Society. Harmonized clinical guidelines on prevention of atherosclerotic vascular disease: executive summary [online]. Available from URL: http://www.athero.org/download/guidelines.pdf [Accessed 2005 May 10].Google Scholar
- 25.Adult Treatment Panel. Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation 2002 Dec; 106(25): 3143–421.Google Scholar
- 27.Pearson TA, Laurora I, Chu H, et al. The Lipid Treatment Assessment Project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med 2000 Feb; 160(4): 459–67.PubMedCrossRefGoogle Scholar
- 32.Singapore Department of Statistics. Statistics Singapore 2005 [online]. Available from URL: http://www.singstat.gov.sg/ [Accessed 2005 May 10].Google Scholar
- 41.Ministry of Health Singapore. National Health Survey 2004 [online]. Available from URL: http://www.moh.gov.sg/corp/hottopics/NationalHealthSurvey/index.do#31457517 [Accessed 2006 Jan 29].Google Scholar