Persons with known coronary heart disease (CHD) are at a greater risk of subsequent events. The current guidelines for secondary prevention have focused on lifestyle modifications, risk factor control, and drug therapy. However, current data lack information on the United States population and its adherence to these guidelines. Using data from the National Health and Nutrition Examination Survey from 2007 to 2010, we identified those with CHD and assessed the adequacy of their adherence to the current guidelines for secondary prevention. Of 759 subjects with CHD (weighted to 12.7 million), the use of recommended therapies was 55%, 45%, and 62% for β blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and lipid-lowering agents, respectively (24% for all), with adherence lower in women than in men and in blacks and Hispanics than in whites. The nonsmoking status and control of blood pressure, low-density lipoprotein cholesterol, and, for those with diabetes, glycated hemoglobin was 73%, 67%, 59%, 60%, respectively (14% for all). Also, 17%, 70%, and 7% were at the recommended levels for physical activity, alcohol consumption, and sodium intake, respectively. Moreover, only 20% and 29% were at the recommended body mass index and waist circumference targets, respectively. Those with metabolic syndrome and diabetes were more likely to have ≥2 risk factors uncontrolled, despite being more likely to be receiving recommended therapies. A significant gap still exists between the secondary prevention guidelines and their adherence and control of CHD risk factors among United States adults. In conclusion, greater efforts are needed to ensure adherence to all aspects of secondary prevention guidelines to optimize the prognosis in subjects with CHD.
Cardiovascular disease, which includes coronary heart disease (CHD), stroke, and peripheral artery disease, is the leading cause of morbidity and mortality in the United States and worldwide. Recent clinical trials have shown in those with CHD that comprehensive risk factor control and lifestyle modification reduces the risk of recurrent CHD events, the need for revascularization procedures, and improves survival and quality of life. Previous studies have also shown that β blockers, angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blocker (ARBs), statins, and antiplatelets each reduce death and reinfarction in patients with established CHD. Although such drugs are widely recommended for prophylactic treatment of patients with known CHD, cardiovascular risk factor control and adherence to national guidelines and their recommended therapies have remained suboptimal. The objective of the present study was to evaluate the adequacy of risk factor control according to the secondary prevention guidelines, including the recommended lifestyle and pharmacologic therapies in United States adults with CHD from the National Health and Nutrition Examination Survey from 2007 to 2010.
Methods
We examined data from United States adults aged 18 to 80 years with a self-reported history of CHD from the National Health and Nutrition Examination Surveys (NHANES) 2007 to 2008 and 2009 to 2010, a cross-sectional study representative of the United States population conducted on noninstitutionalized adults by the Centers for Disease Control and Prevention (Bethesda, Maryland). The interviewers conducted surveys that ascertained information on self-reported demographics, lifestyles, socioeconomic characteristics, and health-related questions. The interviewers also performed a mobile medical examination that provided body composition and serologic information. All subjects provided written informed consent.
A self-report of CHD was defined as a physician informing the subject they had angina pectoris, myocardial infarction (“heart attack”), or CHD. Socioeconomic status was classified according to the annual household income: low, <$35,000; middle, $35,000 to $75,000; and high, >$75,000. Educational status was classified according to the highest degree attained: less than high school, high school diploma or equivalent, and associate degree or greater.
Referring to the American Heart Association/American College of Cardiology Foundation Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease Guidelines, we analyzed 3 aspects of secondary prevention: risk factor control, recommended lifestyle changes, and pharmacologic treatment. Risk factor control included blood pressure, lipids, body mass index, waist circumference, and smoking status, plus the glycated hemoglobin levels for those with diabetes mellitus. The recommended lifestyle changes focused on sodium intake, alcohol consumption, and physical activity. Pharmacologic treatment focused on the use of ACEI/ARBs and/or β blockers. The specific risk factor goals or desirable levels were defined as follows: blood pressure <140/90 mm Hg (130/80 mm Hg for those with diabetes mellitus or chronic kidney disease ), low-density lipoprotein (LDL) cholesterol <100 mg/dl, body mass index 18.5 to <25 kg/m 2 , waist circumference <89 cm for women or <102 cm for men, and glycated hemoglobin <7% for those with diabetes. Diabetes was defined according to a fasting glucose level ≥126 mg/dl or a nonfasting glucose level ≥200 mg/dl, the self-reported use of antidiabetic agents or insulin, or a physician diagnosis of diabetes.
The recommended levels for lifestyle factors included complete smoking cessation, physical activity for ≥150 min/wk or a minimum of 5 days/wk ≥30 min/day, a sodium intake of <1,500 g/day, and alcohol consumption of ≤2 drinks/day for men or 1 drink/day for women. Pharmacologic therapy was assessed by whether the subject indicated that they were taking β blockers, ACEI/ARBs, and/or lipid-lowering agents. This information was collected through the household interview. The participants were asked whether they had taken these medications in the past 30 days. Those who answered “yes” were asked to show the interviewer the medication container. If the medication container was not available, the interviewer asked the participant to verbally report the name of the medication.
Blood pressure measures used in the present analysis were the mean of no more than 4 readings using a mercury sphygmomanometer. Total cholesterol and triglycerides were measured enzymatically using plasma or serum samples with a series of coupled reactions. High-density lipoprotein cholesterol was measured directly from serum. The LDL cholesterol level was calculated using the Friedwald equation when the triglycerides were <400 mg/dl. Glycated hemoglobin measurements used high-performance liquid chromatography with a fully automatic glycohemoglobin analyzer, which has shown excellent long-term precision and an interassay coefficients of variation of <3.0%. The estimated glomerular filtration rate was calculated using the Modification of Diet in Renal Disease formula for creatinine in mg/dl: estimated glomerular filtration rate = 186 × serum creatine −10,154 × age −0.2.3 × [1.212 if black] × [0.742 if female]. Chronic kidney disease was defined as an estimated glomerular filtration rate <60 mg/dl. All measurements and assessments were based on the NHANES Laboratory/Medical Technologies Procedure Manual.
Cross-tabulations were used to examine the proportion of those at goal for the risk factors and recommended lifestyle or pharmacologic therapies overall and by the presence of co-morbidities. Risk factor means were calculated using the least square means. Multiple logistic regression analysis was used to examine the independent association of age, gender, race, socioeconomic status, education status, and co-morbidities on the likelihood of control of blood pressure and LDL cholesterol, having multiple (2+) risk factors uncontrolled, or not receiving the recommended medications (β blocker, ACEI/ARB, or lipid-lowering agents). The Student t test was used to compare the mean values, and the Pearson chi-square test was used for proportions, with Fisher’s exact test used for cells with <5 observations. All statistical analyses were done using Statistical Analysis Systems statistical software, version 9.2 (SAS Institute, Cary, North Carolina). Weighted estimates used SUDAAN, version 10.1 (Research Triangle Institute, Research Triangle Park, North Carolina) for projection to the United States population.
Results
Of the 10,158 subjects interviewed, we identified 759 adults aged ≥18 years with known CHD (weighted to 12.7 million; Table 1 ). The average age was 64.5 years, and 36% were women. Most subjects were white and reported having health insurance. Women were more likely than the men to have hypertension, abdominal obesity, chronic kidney disease, and metabolic syndrome. They also had greater levels of high-density lipoprotein cholesterol and lower LDL cholesterol levels.
| Characteristic | Overall (n = 759) | Men (n = 484) | Women (n = 275) | p Value ∗ |
|---|---|---|---|---|
| Mean age (yrs) | 64.5 | 64.5 | 64.6 | 0.9 |
| Race | ||||
| Non-Hispanic white | 482 (83) | 335 (66) | 147 (34) | 0.09 |
| Hispanic | 146 (8) | 82 (59) | 64 (41) | |
| Non-Hispanic black | 105 (9) | 60 (55) | 45 (45) | |
| Current health insurance (n = 375) | 342 (92) | 216 (92) | 126 (91) | 0.65 |
| Diabetes mellitus | 263 (32) | 163 (31) | 100 (34) | 0.61 |
| Hypertension | 584 (73) | 360 (69) | 224 (81) | 0.005 |
| Mean systolic blood pressure (mm Hg) | 127.8 | 126.7 | 129.8 | 0.1 |
| Mean diastolic blood pressure (mm Hg) | 67.1 | 67.9 | 65.6 | 0.08 |
| Mean LDL cholesterol (n = 379) (mg/dl) | 98.5 | 94.5 | 105.2 | 0.01 |
| Mean HDL cholesterol (mg/dl) | 48.5 | 46.0 | 53.0 | <0.0001 |
| Current smoker | 216 (27) | 143 (28) | 73 (26) | 0.71 |
| BMI ≥25 kg/m 2 | 599 (79) | 387 (81) | 212 (77) | 0.28 |
| Abdominal obesity | 524 (71) | 319 (68) | 205 (78) | 0.02 |
| Angina | 263 (36) | 154 (32) | 109 (41) | 0.06 |
| Myocardial infarction | 452 (59) | 312 (62) | 140 (53) | 0.06 |
| Congestive heart failure | 182 (22) | 118 (21) | 64 (24) | 0.49 |
| Stroke | 119 (17) | 69 (14) | 50 (21) | 0.08 |
| Metabolic syndrome | 321 (57) | 183 (50) | 138 (68) | 0.0007 |
| Chronic kidney disease | 164 (20) | 92 (15) | 72 (30) | 0.0002 |
Men were more likely to have LDL cholesterol levels <100 mg/dl than women, non-Hispanic black men were least likely to have been never or past smokers, those of low socioeconomic status were least likely to have been never or past smokers or to have an LDL cholesterol level <100 mg/dl, and those with less than a high school education were least likely to have been never or past smokers or to have a glycated hemoglobin level <7% (among those with diabetes; Table 2 ). Non-Hispanic whites were most likely and those with less than a high school education least likely to be at all 4 goals.
| Group | Smoking Status | Blood Pressure | LDL Cholesterol <100 mg/dl | HbA1c <7% | All 4 Goals |
|---|---|---|---|---|---|
| Overall | 543 (73) | 485 (67) | 214/379 (59) | 154/263 (60) | 90 (14) |
| Gender | |||||
| Male | 345 (72) | 318 (69) | 145 (64) ∗ | 92 (58) | 64 (15) |
| Female | 198 (74) | 167 (63) | 69 (51) | 62 (65) | 26 (12) |
| Age (yrs) | |||||
| <65 | 166 (59) † | 206 (72) ∗ | 70 (53) | 51 (52) | 28 (14) |
| ≥65 | 377 (84) | 279 (63) | 144 (64) | 103 (66) | 62 (14) |
| Non-Hispanic white | 352 (76) † | 318 (68) | 143 (62) | 91 (62) | 64 (16) † |
| Male | 245 (75) | 225 (70) | 102 (65) | 57 (58) | 49 (17) |
| Female | 107 (76) | 93 (64) | 41 (56) | 34 (70) | 15 (13) |
| Hispanic | 118 (77) | 92 (68) | 38 (44) | 30 (48) | 18 (12) |
| Male | 60 (68) † | 55 (73) | 20 (41) | 14 (43) | 8 (8) |
| Female | 58 (89) | 37 (61) | 18 (47) | 16 (55) | 10 (18) |
| Non-Hispanic black | 56 (50) | 56 (54) | 26 (53) | 27 (62) | 6 (5) |
| Male | 33 (50) | 31 (52) | 18 (69) † | 16 (66) | 5 (7) |
| Female | 23 (49) | 25 (58) | 8 (35) | 11 (57) | 1 (2) |
| Socioeconomic status | |||||
| Low | 249 (63) † | 245 (63) | 98 (50) ∗ | 86 (65) | 38 (10) |
| Middle | 170 (78) | 148 (74) | 66 (63) | 44 (53) | 30 (17) |
| High | 97 (83) | 70 (66) | 39 (71) | 20 (66) | 20 (18) |
| Educational status | |||||
| Less than high school | 182 (59) † | 176 (64) | 75 (52) | 55 (52) ∗ | 20 (7) † |
| High school | 138 (75) | 124 (69) | 52 (65) | 44 (59) | 25 (15) |
| AA or greater | 223 (81) | 185 (68) | 87 (61) | 55 (70) | 45 (18) |
∗ p <0.05 between gender, age, socioeconomic status, or educational groups.
† p <0.01 between gender, age, socioeconomic status, or educational groups.
Adherence to lifestyle recommendations is reported in Table 3 . Only 17% subjects reported doing some regular physical activity; those with greater socioeconomic status were most likely to have regular physical activity. The percentage of subjects with alcohol consumption and sodium intake within the recommended levels was 71% and 7% overall, respectively, with men and non-Hispanic whites most likely to be at the recommended alcohol levels but least likely to be within the recommended sodium intake. Those of low socioeconomic status and with less than a high school education were least likely to be at the recommended levels of physical activity or alcohol use but were most likely to be at the recommended levels of sodium intake.
| Group | Physical Activity | Alcohol Consumption | Sodium Intake | BMI | Waist Circumference |
|---|---|---|---|---|---|
| Overall | 103 (17) | 256 (71) | 65 (7) | 150 (21) | 206 (29) |
| Gender | |||||
| Male | 68 (17) | 192 (75) ∗ | 25 (4) † | 98 (19) | 155 (32) ∗ |
| Female | 35 (16) | 64 (59) | 40 (13) | 52 (24) | 51 (22) |
| Age (yrs) | |||||
| <65 | 47 (23) | 84 (58) | 22 (6) | 56 (19) | 86 (28) |
| ≥65 | 56 (12) | 172 (84) | 43 (8) | 94 (22) | 120 (29) |
| Non-Hispanic white | 70 (18) | 192 (76) † | 30 (6) † | 104 (21) | 130 (27) |
| Male | 47 (18) | 149 (80) † | 10 (2) † | 63 (17) † | 96 (28) |
| Female | 23 (18) | 43 (64) | 20 (13) | 41 (28) | 34 (25) |
| Hispanic | 16 (12) | 33 (44) | 24 (19) | 17 (14) | 39 (31) |
| Male | 10 (14) | 20 (37) | 10 (15) | 15 (21) † | 30 (43) † |
| Female | 6 (9) | 13 (61) | 14 (24) | 2 (2) | 9 (14) |
| Non-Hispanic black | 13 (14) | 26 (44) | 10 (8) | 22 (23) | 28 (30) |
| Male | 8 (15) | 18 (48) | 5 (8) | 15 (30) | 23 (44) † |
| Female | 5 (14) | 8 (38) | 5 (9) | 7 (13) | 5 (11) |
| Socioeconomic status | |||||
| Low | 46 (11) ∗ | 103 (55) † | 40 (10) † | 81 (22) | 109 (30) |
| Middle | 26 (17) | 86 (83) | 18 (7) | 38 (19) | 54 (26) |
| High | 25 (27) | 63 (79) | 4 (2) | 23 (21) | 36 (31) |
| Education status | |||||
| Less than high school | 34 (12) | 57 (52) † | 40 (14) † | 51 (18) | 77 (27) |
| High school | 29 (21) | 65 (69) | 13 (5) | 35 (19) | 39 (22) |
| AA or greater | 40 (18) | 134 (79) | 12 (4) | 64 (24) | 90 (34) |
∗ p <0.05 between gender, ethnicity, socioeconomic status, and educational groups.
† p <0.01 between gender, ethnicity, socioeconomic status, and educational groups.
The proportion of subjects receiving the recommended pharmacologic therapies included 55% for β blockers, 45% for ACEI/ARBs, 62% for lipid-lowering agents, and 24% for all 3 drugs ( Table 4 ). Men were significantly more likely to be taking these 3 medications than were women (p <0.01). Across ethnic groups, non-Hispanic whites were more likely to be taking β blockers, lipid-lowering agents, and all 3 drugs than were the other ethnicities.
| Group | β Blockers | ACEI/ARB | Lipid-Lowering Agents | All 3 Drugs |
|---|---|---|---|---|
| Overall | 414 (55) | 362 (45) | 471 (62) | 186 (24) |
| Gender | ||||
| Male | 280 (56) | 248 (49) ∗ | 322 (67) † | 140 (28) † |
| Female | 134 (53) | 114 (39) | 149 (53) | 46 (18) |
| Age (yrs) | ||||
| <65 | 132 (46) † | 118 (35) † | 142 (49) † | 61 (20) |
| ≥65 | 282 (63) | 244 (54) | 329 (74) | 125 (28) |
| Non-Hispanic white | 281 (58) † | 238 (47) | 327 (67) † | 129 (27) ∗ |
| Male | 202 (59) | 180 (51) ∗ | 241 (72) † | 103 (31) ∗ |
| Female | 79 (56) | 58 (40) | 86 (57) | 26 (19) |
| Hispanic | 56 (34) | 66 (38) | 83 (52) | 32 (20) |
| Male | 36 (38) | 34 (34) | 48 (51) | 22 (22) |
| Female | 20 (29) | 32 (43) | 35 (54) | 10 (16) |
| Non-Hispanic black | 62 (53) | 48 (41) | 47 (38) | 22 (16) |
| Male | 36 (50) | 29 (43) | 26 (35) | 14 (17) |
| Female | 26 (56) | 19 (38) | 21 (43) | 8 (15) |
| Socioeconomic status | ||||
| Low | 215 (56) | 196 (48) | 226 (57) | 91 (22) |
| Middle | 118 (54) | 96 (44) | 146 (68) | 56 (27) |
| High | 64 (57) | 52 (42) | 79 (65) | 32 (27) |
| Education status | ||||
| Less than high school | 144 (51) | 129 (42) | 173 (59) | 70 (24) |
| High school | 113 (58) | 92 (45) | 122 (65) | 49 (25) |
| AA or greater | 157 (56) | 141 (47) | 176 (62) | 67 (24) |
∗ p <0.05 between gender, age group, or ethnicity.
Of those with co-morbidities ( Table 5 ), the subjects with heart failure were more likely to be taking a β blocker. Those with chronic kidney disease, diabetes, or the metabolic syndrome were more likely to receive β blockers, ACEI, or ARBs, or all 3 drugs.
| Group | β Blockers | ACEI/ARB | Lipid-Lowering Agents | All 3 Drugs |
|---|---|---|---|---|
| Stroke | ||||
| Yes | 65 (52) | 62 (45) | 68 (53) | 31 (24) |
| No | 349 (56) | 300 (45) | 403 (64) | 155 (24) |
| CHF | ||||
| Yes | 117 (66) ∗ | 96 (48) | 112 (63) | 48 (26) |
| No | 297 (52) | 266 (44) | 359 (62) | 138 (24) |
| MetS | ||||
| Yes | 195 (63) ∗ | 171 (50) † | 208 (66) | 92 (29) † |
| No | 107 (48) | 93 (40) | 130 (60) | 45 (20) |
| CKD | ||||
| Yes | 111 (66) ∗ | 95 (57) ∗ | 116 (73) ∗ | 55 (36) ∗ |
| No | 286 (53) | 256 (43) | 339 (61) | 128 (23) |
| Diabetes | ||||
| Yes | 159 (65) ∗ | 149 (58) ∗ | 187 (73) ∗ | 86 (36) ∗ |
| No | 255 (50) | 213 (39) | 284 (57) | 100 (19) |
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