Author + information
- Received June 8, 2018
- Revision received August 2, 2018
- Accepted August 12, 2018
- Published online October 29, 2018.
- David J. Maron, MDa,∗ (, )@StanfordMed,
- G.B. John Mancini, MDb,
- Pamela M. Hartigan, PhDc,
- John A. Spertus, MDd,
- Steven P. Sedlis, MDe,†,
- William J. Kostuk, MDf,
- Daniel S. Berman, MDg,
- Koon K. Teo, MB, BChh,
- William S. Weintraub, MDi,
- William E. Boden, MDj,
- on behalf of COURAGE Trial Group
- aDepartment of Medicine, Stanford University, Stanford, California
- bDepartment of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- cVeterans Affairs Connecticut Healthcare System, West Haven, Connecticut
- dMid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri
- eVeterans Affairs New York Harbor Healthcare System, Manhattan Campus, Cardiology, New York, New York
- fLondon Health Sciences Centre, University Hospital, London, Ontario, Canada
- gCedars-Sinai Medical Center, Los Angeles, California
- hPopulation Health Research Institute, McMaster University, Ontario, Canada
- iMedStar Heart and Vascular Institute, MedStar Washington Hospital Center, Washington, DC
- jVA New England Healthcare System, VA Boston–Jamaica Plain Campus, Boston, Massachusetts
- ↵∗Address for correspondence:
Dr. David J. Maron, Clinical Professor of Medicine, Stanford University School of Medicine, 300 Pasteur Drive, Falk CVRC 265, Stanford, California 94305-5406.
Background Individual risk factor control improves survival in patients with stable ischemic heart disease (SIHD). It is uncertain if multiple risk factor control further extends survival.
Objectives This study determined whether a greater number of risk factors at goal predicted improved survival in SIHD patients.
Methods Of 2,287 participants in the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) trial, 2,102 (92%) had complete ascertainment of 6 pre-specified risk factors: systolic blood pressure, low-density lipoprotein cholesterol, smoking, physical activity, diet, and body mass index. Participants received interventions to control these risk factors. The outcome measure was mortality.
Results During a mean follow-up of 6.8 years, 473 (22.5%) subjects died. In univariate analysis, the greater the number of risk factors controlled, the higher the probability of survival (unadjusted log rank: p < 0.001). In multivariate analysis, the strongest predictors at 1 year of improved survival were being a nonsmoker, regular physical activity, having a systolic blood pressure <130 mm Hg, and following the American Heart Association Step 2 diet. Baseline risk factor values and evidence-based medications did not independently predict survival once risk factor control at 1 year was included in the model. Having 4 to 6 risk factors compared with 0 to 1 risk factor at goal predicted lower mortality (hazard ratios for 4 and 6 controlled risk factors: 0.64; 95% confidence interval: 0.41 to 0.98, and 0.27; 95% confidence interval: 0.09 to 0.79, respectively).
Conclusions The greater the number of risk factors in control, the higher the probability of survival in patients with SIHD. More effective strategies are needed to achieve comprehensive risk factor control, including healthy behaviors. (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation [COURAGE]; NCT00007657)
- guideline-directed medical therapy
- optimal medical therapy
- secondary prevention
- stable ischemic heart disease
↵† Dr. Sedlis is deceased.
This study was supported by the Cooperative Studies Program of the U.S. Department of Veterans Affairs Office of Research and Development, in collaboration with the Canadian Institutes of Health Research (grant number FRN#15191); and by unrestricted research grants from Merck, Pfizer, Bristol-Myers Squibb, Fujisawa, Kos Pharmaceuticals, Datascope, AstraZeneca, Key Pharmaceutical, Sanofi, First Horizon, and GE Healthcare, including in-kind support with U.S. Food and Drug Administration−approved drugs used by study participants. All industrial funding in support of the trial was directed through the U.S. Department of Veterans Affairs. These funding sources had no role in the writing of the manuscript or the decision to submit it for publication. The authors have not been paid to write this paper. The corresponding author has had full access to all the data and final responsibility for the decision to submit for publication. Dr. Mancini has received honoraria from Regeneron, Merck Canada, Amgen, Sanofi, Boehringer Ingelheim, and AstraZeneca; and has been a member of the advisory board for Amgen, Sanofi, Boehringer Ingelheim, and Eli Lilly. Dr. Spertus has served as a consultant to Novartis, Bayer, Amgen, and United Healthcare; and has received grant support from Novartis, Lilly, and Aetna Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received June 8, 2018.
- Revision received August 2, 2018.
- Accepted August 12, 2018.
- 2018 American College of Cardiology Foundation
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