Discordance between physicians' estimation of patient cardiovascular risk and use of evidence-based medical therapy.

Despite clinical trial evidence supporting the use of antiplatelets, angiotensin-converting enzyme inhibitors, and statins for cardiovascular risk reduction in high-risk patients, use of such therapies in real-world outpatients in the prospective Vascular Protection Registry and the Guidelines Oriented Approach to Lipid Lowering Registry was suboptimal (78%, 55%, and 75%, respectively). The most frequent reason physicians cited for nonprescription of statins (33%) was that patients were not high risk enough and/or current guidelines did not support statin use. In conclusion, outpatients at high cardiovascular risk continue to be undertreated as a result of a combination of physician underestimation of cardiovascular risk (knowledge gap) and barriers to implementation of evidence-based therapy (practice gap).

How does the prognosis of diabetes compare with that of established vascular disease? Insights from the Canadian Vascular Protection (VP) Registry.

BACKGROUND: Diabetes mellitus is a major risk factor for atherosclerotic cardiovascular disease. In a large, prospective, practice-based registry (the Vascular Protection Registry), we enrolled patients with vascular disease and/or diabetes, and compared the following features between diabetic and non-diabetic participants: (1) risk factor profiles, (2) utilization of cardioprotective medications, and (3) cardiovascular outcomes in short-term follow-up. METHODS: Patients were enrolled by participating physicians practicing in family medicine or specialty practices across Canada. The primary outcome was a composite of the first occurrence of any of the following vascular events: myocardial infarction, unstable angina, coronary revascularization, stroke, transient ischemic attack, or death. Patients were stratified according to the presence or absence of cardiovascular disease and diabetes. RESULTS: In all, 3297 patients were available for analysis (972 [30%] with diabetes but no cardiovascular disease; 899 [27%] with both diabetes and cardiovascular disease; and 1425 [43%] with cardiovascular disease but no diabetes). Most of the measured risk factors were worse for patients with diabetes. Compared to non-diabetic patients, diabetes was associated with substantial undertreatment with cardioprotective medications, including antiplatelet agents, beta blockers, and statins. During a mean follow-up of 10 (SD 3.3) months, patients with both diabetes and cardiovascular disease had the worst prognosis, with the primary outcome occurring at a rate of 16.3 per 100 person-years of follow-up. CONCLUSIONS: Patient registries provide a powerful tool for examining treatment patterns, risk factors, and outcomes. Patients with both cardiovascular disease and diabetes had the highest rates of adverse vascular outcomes. Possible reasons include relatively worse risk factor profiles and undertreatment with proven cardiovascular medications.