Department of Medicine, Stanford University, Stanford, California.
Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
J Am Coll Cardiol. 2018 Nov 6;72(19):2297-2305. doi: 10.1016/j.jacc.2018.08.2163.
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.
This study determined whether a greater number of risk factors at goal predicted improved survival in SIHD patients.
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.
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).
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).
个体危险因素控制可改善稳定性缺血性心脏病（SIHD）患者的生存。但多危险因素控制是否能进一步延长生存尚不确定。
本研究旨在确定目标中存在更多危险因素是否可预测 SIHD 患者的生存改善。
COURAGE（经血管重建和强化药物治疗的临床转归评估）试验共纳入 2287 例患者，其中 2102 例（92%）完全确定了 6 项预先指定的危险因素：收缩压、低密度脂蛋白胆固醇、吸烟、体力活动、饮食和体重指数。参与者接受干预以控制这些危险因素。主要终点是死亡率。
在平均 6.8 年的随访期间，473 例（22.5%）患者死亡。单因素分析显示，控制的危险因素数量越多，生存的可能性越高（未经调整的对数秩检验：p<0.001）。多因素分析显示，1 年时生存改善的最强预测因素是非吸烟者、规律体力活动、收缩压<130mmHg 以及遵循美国心脏协会第 2 步饮食。一旦将 1 年时的危险因素控制纳入模型，基线危险因素值和基于证据的药物并不能独立预测生存。与目标时仅控制 0-1 个危险因素相比，控制 4-6 个危险因素的患者死亡率更低（控制 4 个和 6 个危险因素的风险比分别为 0.64，95%置信区间：0.41 至 0.98，和 0.27，95%置信区间：0.09 至 0.79）。
SIHD 患者控制的危险因素越多，生存的可能性越高。需要更有效的策略来实现全面的危险因素控制，包括健康行为。（COURAGE：经血管重建和强化药物治疗的临床转归评估；NCT00007657）。
