The REACH (Reduction of Atherothrombosis for Continued Health

One-Year Cardiovascular Event Rates in Outpatients With Atherothrombosis

Reference: JAMA 2007; 297: 1197-1206,http://jama.ama-assn.org/cgi/content/abstract/297/11/1197

This study suggests that outpatients with established atherosclerotic arterial disease and those with multiple risk factors for atherosclerosis, experience relatively high annual CVD event rates. These findings reinforce the continued efforts that need to be directed toward the primary and secondary prevention of underlying atherosclerosis so that fatal and nonfatal events can be prevented or delayed to an older age.

Authors: PG Steg, DL Bhatt, PWF Wilson, R D'Agostino, EM Ohman, J Röther, C-SLiau, AT Hirsch, J-L Mas, Y Ikeda, MJ Pencina, S Goto, for the REACH RegistryInvestigators

Reviewer: Robert Goldberg, PhD, ProCOR Contributing Editor

Problem addressed: Contemporary natural history of outpatients with atherosclerotic disease or multiple risk factors for CVD.Purpose of study: To examine contemporary, and multinational, one year even trates of CVD in outpatients with established arterial disease or with multiple coronary risk factors.

Location of study: Paris, France.

Study design: Prospective

Results: The REACH (Reduction of Atherothrombosis for Continued Health) registry includes data on adult (>= 45 years) outpatients with established CVD, CAD, or peripheral vascular disease, as well as in those with at least three riskf actors for atherothrombosis being present. These high-risk patients were recruited from nearly 5600 physician practices in 44 countries between December 2003 and June 2004. Follow-up data were collected at approximately one year after study enrollment and information was collected about the occurrence of fatal and non-fatal eventsof stroke, MI, or CVD in the study sample. A total of nearly 65,000 patients were enrolled in this study. Approximately two-thirds were men, 44% had a history of diabetes, 82% had prior hypertension, nearly one in three were obese, and the average age of the study sample was 69 years. Approximately three quarters of study enrollees were being treated with antiplatelet therapy, nearly half were prescribed beta blockers, 69% were on statin therapy, and nearly 40% were on an antidiabetic agent at the time of study entry. As expected, both the frequency of coronary risk factors and treatment practices varied between the different geographic locales under study.Over the course of the one-year follow-up, all-cause mortality was 2.6%; the death rates were nearly twice as high in those with established arterial diseaseas compared to those with multiple coronary risk factors (2.8% vs. 1.5%). The overall rate of combined events of CVD death, MI, or stroke was 4.2%, again being approximately two fold higher in those with established atheroscleroticarterial disease (4.7%) as compared to those with multiple risk factors only(2.2%). Moreover, the one-year event rates of CVD, MI, stroke, or related hospitalizations also varied inversely with the presence of established arterial disease as compared to those with multiple risk factors only.In addition to the occurrence of these fatal and nonfatal events, the frequency of the pooled CVD endpoint increased with the number of symptomatic arterial disease locations present. For example, 5.3% of patients with multiple CHD riskfactors developed this aggregate endpoint compared to 12.6%, 21.1%, and 26.3% of patients with one, two, and three symptomatic arterial disease locations,respectively. In terms of geographic variation, participants from Japan experienced the lowest rates of all study endpoints whereas the highest event rates were observed in the Middle East and Eastern Europe.

Discussion: The results of this large multi-site international study suggestthat outpatients with established atherosclerotic arterial disease, as well as those with multiple risk factors for atherosclerosis, experience relatively high annual event rates of CVD, with these rates varying according to the underlying burden of disease. Indeed, over the course of the one-year follow-up period, approximately one in every seven patients with underlying arterial disease experienced either a hard CVD endpoint or required hospitalization for anatherosclerotic event. These events were noted despite the relatively high use of secondary preventive modalities in the study sample, though the utilization of several agents was less than optimal, and relatively few patients were attarget goals for body weight, BP, or serum cholesterol levels.The present results clearly identify groups at increased risk for adverse events in whom lifestyle modifications and more optimal management with proven treatment regimens remain needed. These findings reinforce the continued efforts that need to be directed toward the primary and secondary prevention of underlying atherosclerosis so that both fatal and nonfatal events of the various manifestations of this disease process can be prevented or delayed to an olderage.


Colin Rose MD PhD, Cardiologist, Associate Professor of Medicine, McGill University, faz severas crítcas ao artigo e particularmente questões vinculadas aos conflitos de intereese (financial disclosure) dos pesquisadores e também do editorialista da JAMA.

Readers should be made aware of the disclosure of Dr. McDermott, the editorialist:

Financial Disclosures: Dr McDermott reports that she has received honoraria from Bristol-Myers Squibb, Sanofi-Aventis, NicOx, and Otsuka Pharmaceutical, has served as a consultant for Hutchinson Technology, and is currently receiving support from research grants from the National Heart, Lung, and Blood Institute.

Comentários de Colin Rose:

Why couldn’t JAMA find an editorialist with no connection to “industry”, particularly the company funding the study which was editorialized?

If you wonder why this is a “free” publication just look at the disclosures and funding:

Financial Disclosures:
Dr Bhatt reports that he has received honoraria for consulting on scientific advisory boards from AstraZeneca, Bristol-Myers Squibb, Centocor, Eisai, Eli Lilly, GlaxoSmithKline, Millennium, Otsuka, Paringenix, PDL, Sanofi-Aventis, Schering Plough, The Medicines Company; honoraria for lectures from Bristol-Myers Squibb, Sanofi-Aventis, and The Medicines Company; and provided expert testimony regarding clopidogrel (the compensation was donated to a nonprofit organization).
Dr Röther reports that he has received honoraria from Bristol-Myers Squibb and Sanofi-Aventis. Dr Steg reports that he has received honoraria from Bristol-Myers Squibb and Sanofi-Aventis and has received research grants from Sanofi-Aventis.
Dr Steg reports having served as a member of the speakers’ bureau for Boehringer Ingelheim, Servier, GlaxoSmithKline, Merck, Sharp & Dohme, and Nycomed and also on a consultant ad board for AstraZeneca, Bristol-Myers Squibb, GlaxoSmithKline, Merck, Sharp & Dohme, Sanofi-Aventis, Servier, and Takeda.
Dr Ohman reports that he has received research grants from Berlex, Sanofi-Aventis, Schering-Plough, Eli Lilly, Bristol-Myers Squibb, and Millennium. Dr Ohman reports that he has stock ownership in Medtronic, Savacor, and Response Biomedical and is a consultant for Invoise, Response Biomedical, Savacor, and Liposcience.
Dr Hirsch reports that he has received research grants from Bristol-Myers Squibb and Sanofi-Aventis; honoraria from Sanofi-Aventis; and speaker’s bureau fees for Sanofi-Aventis.
Dr Wilson reports that he has received a grant from Sanofi-Aventis.
None of the other authors reported disclosures.

Funding/Support: The REACH Registry is sponsored by Sanofi-Aventis, Bristol-Myers Squibb, and the Waksman Foundation (Tokyo, Japan), who assisted with the design and conduct of the study and data collection.

Comentários de Colin Rose:

Call me paranoid but I have a suspicion that the conclusion of the next paper from REACH will be that “dual anti-platelet” therapy (read ASA and Plavix) is underused. Thus the “reduction” in REACH.


Comentários finais do Dr. Colin Rose:

In the final analysis, what is the point in studying atherosclerosis in a population in which 80% are overweight or obese, 44% are diabetic, 82% are hypertensive and 16% are smoking? The causes of their atherosclerosis are obvious, food and/or tobacco addictions as we have known for many years.

If sanofi-aventis and Bristol-Myers Squibb really want to reduce “atherothrombosis” and improve health they should fund programs for fighting these addictions instead of doing more surveys to try to justify more drug sales. From their own data it is clear that drugs do not increase life expectancy.