Evidence-Based Complementary and Alternative Medicine

Volume 2013 (2013), Article ID 162501, 6 pages

http://dx.doi.org/10.1155/2013/162501

Research Article

Analysis on Outcome of 3537 Patients with Coronary Artery Disease: Integrative Medicine for Cardiovascular Events

Zhu-ye Gao,¹ Yu Qiu,² Yang Jiao,³ Qing-hua Shang,¹ Hao Xu,¹ and Da-zhuo Shi¹

¹Department of Cardiology, Xiyuan Hospital, China Academy of Chinese Medical Sciences, Beijing 100091, China

²Chinese Journal of Integrated Traditional and Western Medicine, Beijing 100091, China

³Beijing University of Chinese Medicine, Beijing 100029, China

Received 22 April 2013; Accepted 25 June 2013

Academic Editor: Ke-ji Chen

Copyright © 2013 Zhu-ye Gao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract.

Aims. To investigate the treatment of hospitalized patients with coronary artery disease (CAD) and the prognostic factors in Beijing, China. Materials and Methods. A multicenter prospective study was conducted through an integrative platform of clinical and research at 12 hospitals in Beijing, China. The clinical information of 3537 hospitalized patients with CAD was collected from September 2009 to May 2011, and the efficacy of secondary prevention during one-year followup was evaluated. In addition, a logistic regression analysis was performed to identify some factors which will have independent impact on the prognosis. Results. The average age of all patients was 64.88 ± 11.97. Of them, 65.42% are males. The medicines for patients were as follows: antiplatelet drugs accounting for 91.97%, statins accounting for 83.66%, β-receptor blockers accounting for 72.55%, ACEI/ARB accounting for 58.92%, and revascularization (including PCI and CABG) accounting for 40.29%. The overall incidence of cardiovascular events was 13.26% (469/3537). The logistic stepwise regression analysis showed that heart failure (OR, 3.707, 95% CI = 2.756–4.986), age ≥ 65 years old (OR, 2.007, 95% CI = 1.587–2.53), and myocardial infarction (OR, 1.649, 95% CI = 1.322–2.057) were the independent risk factors of others factors for cardiovascular events that occurred during followup of one-year period. Integrative medicine (IM) therapy showed the beneficial tendency for decreasing incidence of cardiovascular events, although no statistical significance was found (OR, 0.797, 95% CI = 0.613~1.036). Conclusions. Heart failure, age ≥ 65 years old, and myocardial infarction were associated with an increase in incidence of cardiovascular events, and treatment with IM showed a tendency for decreasing incidence of cardiovascular events.

1. Introduction

According to research, the risk factors like hypertension, diabetes mellitus, dyslipidemia, and smoking have a positive correlation with CAD. If the numbers of risk factors reduced, the incidence of CAD will decrease significantly. European Society of Cardiology (ESC), American Heart Association (AHA), American College of Cardiology (ACC), and Chinese Medical Association have published in succession clinical guidelines on angina pectoris, myocardial infarction, hypertension, and dyslipidemia, which have played an important role in improving secondary prevention of CAD. However, the implementation of the previously mentioned guidelines in clinical practice IM hospitals in China and the potential benefit of IM therapy in improving CAD prognosis remain unclear. The previous study showed that the treatment of IM can prevent restenosis after PCI [1] and potentially decrease the incidence of cardiovascular events [2]. In this study, we performed a prospective research for CAD patients who were hospitalized in cardiovascular departments in twelve hospitals in Beijing from September 2009 to May 2011 for analyzing the secondary prevention status of CAD. We also investigate the one-year following incidence of cardiovascular events with the purpose of the problem of secondary prevention and the potential role of IM.

2. Materials and Methods

2.1. Patients

3537 patients were recruited from 12 hospitals in Beijing, China. The research followed guidelines of the Declaration of Helsinki and Tokyo for humans and was approved by the Institutional Human Experimentation Committee, and an informed consent was obtained. The source of patients was shown in Table 1.

Table 1: Source of patients.

Hospital
Case (male/female)
Percentage of total

Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine
178 (111/67)
5.03%

Guanganmen Hospital affiliated to China Academy of Chinese Medical Science
564 (363/201)
15.95%

Huairou Hospital of Traditional Chinese Medicine
121 (77/44)
3.42%

Beijing Hospital of Traditional Chinese Medicine
220 (142/78)
6.22%

People’s Hospital affiliated to Beijing University
107 (72/35)
3.03%

Tongzhou Hospital of Traditional Chinese Medicine
160 (98/62)
4.52%

Tongren Hospital affiliated to Capital University of Medical Sciences
260 (162/98)
7.35%

Wangjing Hospital affiliated to China Academy of Chinese Medical Science
93 (58/35)
2.63%

Xiyuan Hospital affiliated to China Academy of Chinese Medical Science
462 (304/158)
13.06%

China-Japan Friendship Hospital
632 (425/207)
17.87%

Beijing Hospital of Integrated Traditional Chinese with Western Medicine
124 (80/44)
3.51%

Anzhen Hospital affiliated to Capital University of Medical Sciences
616 (422/194)
17.42%

2.2. Inclusion and Diagnostic Criteria

Inclusion Criteria. These include the following:

(1) a hospital with CAD (angina pectoris, myocardial infarction, heart failure, or arrhythmia);(2)complying with one of the following conditions:

(a) old myocardial infarction;(b)acute myocardial infarction diagnosed in hospital;(c)coronary artery stenosis >50% confirmed by coronary angiography.

2.3. Evaluation Methods

The diagnostic and therapeutic statuses of CAD patients were evaluated based on relevant clinical guidelines including guidelines for the diagnosis and treatment of chronic unstable angina pectoris and myocardial infarction [3] published by Chinese Medical Association Cardiovascular Society, guidelines for diagnosis and treatment of unstable angina pectoris [4], guidelines for diagnosis and treatment of myocardial infarction [5] published by American Heart Association (AHA) and American College of Cardiology (ACC), clinical guidelines about heart failure [6, 7], guidelines for diagnosis and prevention of hypertension [8, 9], diagnosis and prevention of dyslipidemia, and National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) [10, 11].

2.4. Definition of Cardiovascular Events

This include the following:

(i)death due to any cause;(ii)acute myocardial infarction;(iii)revascularization is needed.

2.5. Materials

2.5.1. Data Collection

 Research process in accordance with the subject of the investigator’s brochure. The clinical researchers were all trained and they passed the examination. The clinical data collected by an integrative platform of clinical and research was analyzed after clearing up. The treatment of IM means that the patient accepts the conventional treatment of modern medicine and the treatment of herbal medicine including both herbal-based injection and Chinese patent medicine, as well as decoction for at least 7 days in-hospital or 3 months out of hospital.

2.5.2. Followup

 The follow-up was mainly through telephone. Home visit will be implemented if we cannot contact patients with telephone. The latest clinical data will be used if the patient lost to followup.

2.5.3. Observation Index

Demographic data, general clinical condition, drug use, and outcome of followup were observed.

2.5.4. Statistics

Statistical analysis of the experimental data was carried out using SPSS (version 11.0). Patients’ demographic and clinical characteristics were analyzed with descriptive analytic method and the chi-square test for categorical variables. Continuous variables were presented as mean with standard deviation, and categorical variables were expressed as frequencies with percentages. Logistic regression analysis using fractional polynomial modeling was conducted to determine the association between demographic and clinical information and mortality in MACEs. The criterion for statistical significance was at .

3. Results

3.1. Demographics and Clinical Characteristics

3537 consecutive hospitalized CAD patients were enrolled into the study, which was approved by the Local Ethic Committee. The average age in patients was years (range 24–96). The number of males is 2314, accounting for 65.42%. 795 patients had a history of smoking, accounting for 22.5%. The average history of smoking was years (range 1–70). 327 patients had a history of drinking.

3.2. Subtype of CAD and Complicating Disease

The 3537 patients were divided into four groups through the first diagnosis which contain angina pectoris, acute myocardial infarction, arrhythmia, and heart failure. The group of angina pectoris includes 2212 patients, accounting for 62.54%. The group of acute myocardial infarction includes 836 patients, accounting for 23.92%. The group of arrhythmia includes 244 patients, accounting for 6.90%. The group of heart failure includes 235 patients, accounting for 6.64%. The status of complicating diseases was shown in Table 2.

Table 2: Status of complicating disease.

Complicating disease
Number
Percentage of total

Hypertension
2398
67.80%

Diabetes mellitus
1162
32.85%

Dyslipidemia
1161
32.82%

Old myocardial infarction
741
20.95%

Stroke
496
14.02%

Chronic obstructive pulmonary disease (COPD)
397
11.22%

Peripheral vasculopathy
165
4.66%

Chronic kidney disease
154
4.35%

3.3. Status of Treatment

Displayed in Table 3 are the numbers and rates of each medication, coronary artery revascularization and Chinese herbal medicine, which patients had received treatment of IM.

Table 3: Status of treatment.

Treatment
Number
Percentage of total

IM therapy
1459
41.25%

PCI or CABG
1425
40.29%

Antiplatelet agents
3253
91.97%

Statins
2959
83.66%

Nitrate medications
2709
76.59%

-receptor blockers
2566
72.55%

Heparin
1905
53.86%

ACEI and ARB
2084
58.92%

Calcium channel blockers
1137
32.15%

Insulin
471
13.32%

3.4. Prognostic Analysis

3.4.1. Prognostic Status

312 patients were lost to followup, accounting for 8.82%. The average age was (range 30–90) in the 469 patients with cardiovascular events, accounting for 14.54%. The males are 289, accounting for 61.62%.

3.4.2. Single-Factor Analysis

Table 4 displayed the result of single-factor analysis, in which myocardial infarction, heart failure, stroke, arrhythmia, LDL-C elevating, age ≥ 65 years, and diabetes mellitus were significantly higher in event-group: meanwhile, TG elevating and TC elevating were significantly higher in nonevent group.

Table 4: Single-factor analysis.

Variable
Nonevent group
Event group

Myocardial infarction
39.15%
47.97%
<0.001

Heart failure
6.91%
20.47%
<0.001

Stroke
4.63%
8.53%
0.001

Arrhythmia
18.71%
24.73%
0.003

TG elevating
38.90%
30.79%
0.001

LDL-C elevating
22.27%
27.39%
0.028

TC elevating
23.97%
17.57%
0.004

Age ≥ 65 years
49.28%
68.87%
<0.001

Diabetes mellitus
16.36%
20.68%
0.024

-receptor blockers
73.11%
68.87%
0.059

Insulin
12.91%
15.99%
0.068

Antiplatelet agents
92.28%
89.98%
0.1

IM therapy
40.9%
43.5%
0.291

3.4.3. Logistic Regression Analysis

Based on measured indexes in which in the former analysis and IM therapy, a multiple regression equation was generated between cardiovascular events and indexes. Table 5 displayed the result of logistic stepwise regression analysis, in which heart failure, age ≥ 65 years, and myocardial infarction were the independent negative prognostic factors for cardiovascular events, while TG elevating was the independent protective factor.

Table 5: Analysis of prognostic factors using multivariate logistic stepwise regression.

Variables

OR
95% CI

Heart failure
1.310
<0.001
3.707
2.756–4.986

Age ≥ 65 years
0.697
<0.001
2.007
1.587–2.539

Myocardial infarction
0.500
<0.001
1.649
1.322–2.057

TG elevating
−0.259
0.02
0.754
0.595–0.956

Table 6 displayed the result of logistic regression analysis, in which IM therapy showed potential tendency for decreasing the incidence of cardiovascular events.

Table 6: Analysis of prognostic factors using multivariate logistic regression.

Variables

OR
95% CI

IM therapy
−0.227
0.09
0.797
0.613–1.036

Myocardial infarction
0.386
0.001
1.471
1.172–1.847

Heart failure
1.308
<0.001
3.7
2.737–5.002

Stroke
0.392
0.095
1.48
0.935–2.342

Arrhythmia
0.084
0.536
1.088
0.833–1.42

Antiplatelet agents
−0.115
0.591
0.892
0.587–1.355

-receptor blockers
−0.077
0.548
0.926
0.72–1.19

Insulin
0.333
0.056
1.396
0.991–1.966

TG elevating
−0.208
0.099
0.812
0.635–1.04

LDL-C elevating
0.036
0.846
1.036
0.722–1.487

TC elevating
−0.255
0.206
0.775
0.522–1.15

Age ≥ 65
0.574
<0.001
1.775
1.384–2.278

Different hospital
0.295
0.16
1.343
0.89–2.026

Diabetes mellitus
0.072
0.647
1.075
0.789–1.465

4. Discussions

It is shown that the range of the age of the majority of hospitalized CAD patients’ is from 60 years old to 74 years old, accounting for 41.93% in this study. Event rate of one-year followup of hospitalized CAD patients is 14.54% (469 cases), the average age is years (range 30–90). The probability of recurrent cardiovascular events in patients whose age is that greater than 65 years old is 2.4 times of the patients whose age is lower than 65 years old (18.5% versus 7.6%). It is also suggested that age is an important affecting factor of the prognosis of CAD which cannot be changed. Other studies have confirmed that age is an independent risk factor for CAD prognosis; the rate of CAD incidence and mortality is increasing with age [12–14].

Epidemiological and clinical studies have demonstrated that hypertension, diabetes, dyslipidemia, smoking, obesity, and other risk factors can aggravate atherosclerosis and increase the morality of CAD [15]. It is shown that hypertension, diabetes, dyslipidemia, cerebrovascular disease and COPD are common complications of CAD, and with the development of CAD and the increase of age, complications are more and more serious. One research from abroad shows that once artery atherosclerosis forms, only a simple monitoring of risk factors cannot fully control the progression of disease [16]. The correlative guidelines of CAD also recommend that patients with CAD should insist on long-term drug therapies that include β-receptor blockers, antiplatelet agents, and statin. Overall treatment modalities in this study were similar to the suggestion of relevant guidelines. Although the treatment rate of statins, β-receptor blockers, and ACEI/ARB is more than 50%, neither of these treatments show beneficial effects to decrease the incidence of cardiovascular events. This result is different from previous RCTs; it may be related to the type of design and cases as well as too short follow-up period.

Therefore, as for CAD patients who also have complications, they should pay more attention to the treatment of secondary prevention drugs and to the control of the complications on the long term, for reaching the maximum limit to decrease the incidence of cardiovascular events [17].

Diabetes mellitus was a CAD risk equivalent [18, 19]. It is shown that diabetes and injection of insulin may be attributed to more incidences of cardiovascular events. It may contribute to serious complex illness and poor glycemic control usually accompanying CAD patients who also contract diabetes. It is certificated that the rate of cardiovascular events such as morality in CAD complicating diabetes patients is greater than that in nondiabetes ones in interrelating reach.

It was found that patients in normal left ventricular ejection fraction group and lower left ventricular ejection fraction group have similar prognosis in previous epidemiological investigations and observational studies [20]. But most of those experiment objects have dilated cardiomyopathy, and hypertensive heart disease patients take low proportion in patients with CAD. Moreover most of the clinical trials will usually exclude patients with heart failure whose left ventricular ejection fraction is normal. CAD is one of the important causes of heart failure, and persistent coronary ischemia will further aggravate heart failure. This study also showed that heart failure can increase the incidence of endpoint events. It is important to effectively prevent HF readmissions and improve overall outcomes [21].

In recent years, the combination of medicines rises extensively worldwide, and it is used increasingly in clinical application. IM is a unique discipline in China; it also has a wide range of applications in China [22]. This study shows that, from the results of one-year followup, although IM has no statistical significance in affecting incidence of cardiovascular events, IM therapy showed the tendency of decreasing incidence of cardiovascular events. This also shows that a single drug or treatment could not prevent multiple-factor disease such as CAD. IM has advantages in improving the clinical symptoms especially for CAD patients having diabetes, high blood pressure, lung infection, and kidney disease. It was shown that it has greater advantages in improving the quality of life for patients in previous studies [23, 24]. There are many people willing to adopt the IM treatment for cardiovascular disease [25].

In this study, a lengthways study design was adopted, using traditional Chinese medicine clinical research integrated research platform to investigate and analogize the clinical information and cardiovascular events in patients with CAD from cardiovascular departments of 12 hospitals in Beijing. This research reflects objectively and accurately the treatment and independent prognostic factors of hospitalized CAD patients in Beijing. There are many complications of CAD: high incidence of clinical events and a gap between clinical drugs and guidelines. Therefore, we should strengthen secondary prevention degree and health education for patients with CAD. It needs to control multiple risk factors and intervene complete complex situation to reduce the incidence of complication and the rate of endpoint events.

For the limited follow-up time, this research could not make new diseases as the endpoint, such as new-onset diabetes, new-onset kidney disease, and new-onset heart failure. As IM treatments for CAD have the advantage of being multidimensional and multi-target, further analysis of research material can include factors like the patients’ quality of life, degree of symptom improvement and the different situations of occurred cases. These factors could then be combinedly and systematically evaluated to define the intended population of IM treatments, and thus be used to draw up intervening programs of IM treatments for CAD.

Conflict of Interests

The authors have no conflict of interests to declare.

Authors’ Contribution

Professor Zhu-ye Gao and Dr. Yu Qiu contributed equally to this paper.

Acknowledgments

The authors are indebted to all the staff members of all the participating hospitals for their outstanding efforts: Li-zhi Li, Jing-chun Zhang, Xiao-chang Ma, and Feng-qin Xu, Xiyuan Hospital affiliated to China Academy of Chinese Medical Science; Li Huang, Jin-hang Du, Xiao-yan Lu, Hai-zhong Jia, and Chun-yan Li, China-Japan Friendship Hospital; Yuan-hui Hu, Ling Feng, and Qing-qiao Song, Guanganmen Hospital affiliated to China Academy of Chinese Medical Science; Yan-ming Huo, Rui-lin Zhang, and Guo-hua Yang and Wangjing Hospital affiliated to China Academy of Chinese Medical Science; Xian Wang, Yu-qing Liu, Dongzhimen Hospital affiliated to Beijing University of Chinese Medicine; Hong-jin Wu, Beijing Hospital of Integrated Traditional Chinese with Western Medicine; Hong-xu Liu, Beijing Hospital of Traditional Chinese Medicine; Shu-zheng Lv, Anzhen Hospital affiliated to Capital University of Medical Sciences; Ming-ying Wu, Tongren Hospital affiliated to Capital University of Medical Sciences; Cheng-bin Xu, People’s Hospital affiliated to Beijing University; Shu-yun Zhang, Huairou Hospital of Traditional Chinese Medicine; Yu-quan Zhang, Tongzhou Hospital of Traditional Chinese Medicine. This project was supported by Beijing Committee of Science and Technology (no. D08050703020801), the TCM Public Welfare Scientific Research Project, the State Administration of TCM of People’s Republic of China (no. 201007001), Capital Foundation of Medical Developments (no. SF-2007-II-13, SF-2009-I-09), and the National Science and Technology Major Projects for “Major New Drugs Innovation and Development” (no. 2009ZX09502-031).

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