Revista Española de Cardiología (English Edition) Revista Española de Cardiología (English Edition)
Rev Esp Cardiol. 2014;67:538-44 - Vol. 67 Num.07 DOI: 10.1016/j.rec.2013.10.020

Demographic and Clinical Characteristics of Patients With Stable Coronary Artery Disease: Results From the CLARIFY Registry in Spain

José L. Zamorano a,, Xavier García-Moll b, Roberto Ferrari c, Nicola Greenlaw d

a Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
b Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
c Servicio de Cardiología, Hospital Universitario de Ferrara, Ferrara, Italy
d Robertson Centre for Biostatistics, University of Glasgow, Glasgow, United Kingdom

Keywords

Coronary artery disease. Registry. Risk factors.

Abstract

Introduction and objectives

Coronary artery disease is associated with high morbidity and mortality. The objective of the CLARIFY registry is to study the treatment of outpatients with coronary artery disease in the setting of daily clinical practice.

Methods

The CLARIFY registry is a prospective registry conducted in 41 countries that included outpatients with stable coronary artery disease attending primary care or specialist units between October 2009 and June 2010. The present study describes the baseline characteristics of the Spanish cohort compared with the western European cohorts included in the registry.

Results

A total of 33 248 patients were included: 14 726 in western Europe and 2257 in Spain (selected by 192 cardiologists). The majority of the participants in Spain were men (81%) with a mean age of 65 years. There was a higher frequency of diabetes (34% vs 25%; P < .0001), coronary artery disease family history (19% vs 31%; P < .0001), myocardial infarction (64% vs 60%; P < .0001), and stroke (5% vs 3%; P = .0007) in the Spanish cohort than in the western European cohorts. The most common treatments in the Spanish sample were lipid-lowering drugs (96%), acetylsalicylic acid (89%), and beta-blockers (74%).

Conclusions

Patients in the Spanish cohort are similar to those in the western European cohorts and seem to be representative of the Spanish population with coronary artery disease. Therefore, they form a suitable basis for the study of prognostic factors at 5-year follow-up.

Article

INTRODUCTION

Coronary artery disease (CAD) remains the leading cause of death in Europe.1 However, data released in 2008 show a recent fall in CAD mortality in most European countries, due to advances in prevention strategies and more effective treatments, whereas it has risen in some central and eastern European countries.1 Although these advances have improved CAD outcomes, the number of CAD patients has increased, changing the clinical practice setting and leading to the high economic burden of €192 billion per year in the European Union.1

The high prevalence, morbidity and mortality, and economic burden of CAD have led to changes in the European guidelines on cardiovascular disease prevention.2 These changes include new sections on risk factors, such as heart rate (HR). The importance of HR in the outcome of stable CAD patients has been supported by extensive evidence.3

Information on patients seen in daily clinical practice is needed to determine to what extent the recommendations are being applied and to what degree disease outcomes are improving. Patient data from clinical trials are useful for evaluating treatment, but do not represent clinical practice due to the stringent patient selection process and because patient follow-up and treatment is guided by the trial protocol. Patient registries are the ideal source of information on CAD patients. Although several CAD patient registries have recently been developed, they are limited by being restricted to a particular geographical area4 or by only addressing certain CAD conditions, especially stable angina5 or acute coronary syndrome.6, 7

The CLARIFY8, 9 registry was developed with the main aim of obtaining worldwide data on the treatment of all CAD outpatients in the setting of daily clinical practice and of identifying the determinants, including HR, of long-term outcomes in this population. Even though HR has been associated with increased cardiovascular risk10 it is not yet a routine component of cardiovascular assessment; furthermore, its prognostic value and to what extent it is applied in clinical practice remains unknown. This paper describes and compares the demographic and clinical characteristics of the Spanish cohort with other western European cohorts.

METHODS

CLARIFY is an international prospective registry, launched in 41 countries worldwide. Its main objective is to describe the demographic and clinical characteristics of stable CAD outpatients seen in daily clinical practice by the medical specialists (cardiologists, internists, and primary care physicians) in charge of managing these patients in each participating country. A secondary objective is to develop a risk prediction model by identifying long-term prognostic factors, including resting HR. The CLARIFY study is being conducted in accordance with the principles embodied in the Declaration of Helsinki. The present study was reviewed and approved by the Clinical Research Ethics Committee of the Hospital Clínico San Carlos in Madrid.

The CLARIFY study population consists of stable CAD outpatients attending primary care centers or specialist units (cardiology and internal medicine) worldwide. In each country, the national coordinators selected the participating centers according to the distribution of coronary patients and the health care organizational structure, such that the sample was representative of the epidemiological patterns in each country. Each selected physician included the first 10 consecutive patients attending his or her center who met the eligibility criteria. The national coordinators of the CLARIFY registry in Spain decided that only cardiologists who were based in hospitals or outpatient centers could participate because these specialists are responsible for making decisions about stable CAD patients. The list of researchers is shown in the supplementary material.

The registry includes stable CAD outpatients with at least 1 of the following conditions: documented myocardial infarction that occurred more than 3 months earlier; at least 1 coronary stenosis blocking > 50% of the artery on angiography; chest pain with myocardial ischemia confirmed by stress electrocardiogram, stress echocardiography, or myocardial imaging; coronary artery bypass graft or percutaneous coronary intervention conducted more than 3 months before inclusion. Patients were excluded if they had been hospitalized for cardiovascular disease in the last 3 months, were scheduled for revascularization, or their condition hindered their participation in the study and the 5-year follow-up period.

Patients were recruited between October 2009 and June 2010 worldwide and from April to June 2010 in Spain. All patients will be followed up for 5 years with annual visits. Data collection is by electronic forms translated into the local language. At baseline, patients were evaluated for demographic information, risk factors, lifestyle, medical history, physical examination, current symptoms, data from the most recent tests, and current chronic medical treatments. At the annual visits, this information is updated and data are collected on the patient's clinical course and cardiovascular mortality and morbidity. This is an observational study and thus all the information is collected during daily clinical practice in each center, as documented in the patients’ medical history.

Based on data from previous studies,5 the total size of the sample of the registry was determined by estimating cardiovascular mortality and mortality or cardiovascular events to be 2% and 4.5% per year, respectively. At least 31 000 participants are expected to be selected with an estimated 5% loss to follow-up per year. Thus, the expected number of cardiovascular deaths will be approximately 2300. On the basis of the analysis of HR as a categorical variable (population divided into HR quartiles), we used a conservative approach that compared the highest HR quartile to the other quartiles to establish the risk of cardiovascular mortality. This comparison resulted in a minimum statistical power of 80% to identify a 20% increase in risk for the group with the highest HR. If HR is considered a continuous variable, a power of 90% to detect an instantaneous hazard ratio of 1.06 for each 10 bpm increase in HR would be obtained at a significance level of 5%. In general, each participating country had to recruit a mean of 25 patients (range, 12.5-50) per million population to obtain a representative sample.

The post hoc analysis presented in this article describes the baseline characteristics of the sample in Spain and other western European countries (Germany, Austria, Belgium, Denmark, France, Greece, Ireland, Italy, the Netherlands, Portugal, Switzerland, the United Kingdom) participating in the CLARIFY registry. Continuous variables are expressed as mean (standard deviation) or median [interquartile range] according to the data distribution. Categorical variables are expressed as absolute frequencies and percentages. Continuous variables (Spanish subcohort vs western European subcohorts) were compared using simple analysis of variance (ANOVA) or the Kruskal-Wallis test according to the data distribution. Categorical variables were compared using the chi-square test. In all cases, the results were considered significant when P < .05.

RESULTS

The CLARIFY registry included 33 248 participants from 41 countries, of whom 14 726 were from the western European countries included in the present analysis. A total of 192 cardiologists recruited the 2257 participants from Spain. The demographic characteristics of the patients from Spain and the rest of the sample are summarized in Table 1. The majority of the participants were men (81% in Spain and 79% in the rest of the sample) and mean age was 65 years in the Spanish sample and 66 years in the remaining sample.

Table 1. Sociodemographic Characteristics

  Spain (n = 2257) Other countries (n = 12 469) P
Age, mean (SD), y 65.3 (10.8) 66.3 (10.0)  < .0001
Men 1817 (81) 9889 (79.4) .0756
Caucasian 2133 (94.5) 9010 (72.3) *
Employment      < .0001
Full-time 546 (24.3) 2600 (20.9)  
Half-time 71 (3.2) 661 (5.3)  
Disabled 155 (6.9) 322 (2.6)  
Unemployed 61 (2.7) 322 (2.6)  
Retired 1329 (59.1) 8305 (66.7)  
Other 86 (3.8) 249 (2)  
Education      < .0001
Primary (or less) 1180 (52.5) 3654 (29.3)  
Secondary 739 (32.9) 6186 (49.7)  
University 329 (14.6) 2619 (21.0)  

SD, standard deviation.
* Not calculated.
Unless otherwise indicated, the data are expressed as No. (%).

Risk factors and lifestyle habits are shown in Table 2. The percentage of current smokers was lower in Spain than in the other western European countries, and the percentage of exsmokers was higher in Spain (Table 2). In the Spanish sample, 78% of patients had dyslipidemia, 68% had hypertension, 34% had diabetes mellitus (DM), and 13% had peripheral artery disease. The greatest differences between Spain and the other western European countries were in the prevalence of DM (34% vs 25%, P < .0001) and in having a family history of premature CAD (19% vs 31%, P < .0001). Myocardial infarction (64% vs 60%, P < .0001) and stroke (5% vs 3%, P = .0007) were more common in Spain than in the rest of the sample, whereas carotid artery disease was less common in Spain (5% vs 9%, P < .0001) (Table 3). Table 4, Table 5 show the clinical profile and baseline symptoms of the patients.

Table 2. Risk Factors and Lifestyle Habits

  Spain (n = 2257) Other countries (n = 12 469) P
Family history of premature CAD 429 (19.1) 3805 (30.5)  < .0001
Treated hypertension 1518 (67.5) 8460 (67.9) .7253
Diabetes mellitus 753 (33.5) 3138 (25.2)  < .0001
Dyslipidemia 1743 (77.5) 9520 (76.4) .2464
Peripheral artery disease 297 (13.2) 1537 (12.3) .2482
Smoking      < .0001
Smoker 211 (9.4) 1467 (11.8)  
Exsmoker 1323 (58.9) 6105 (49.0)  
Nonsmoker 714 (31.8) 4888 (39.2)  
Alcohol consumption (drinks/wk)      < .0001
0 980 (43.6) 3974 (31.1)  
> 0 and < 20 1129 (50.2) 7868 (63.2)  
> 20 139 (6.2) 616 (5.0)  
Stimulant drinks      < .0001
Cafe 1061 (47.2) 7693 (61.8)  
Tea 53 (2.4) 2576 (20.7)  
None 1134 (50.4) 2188 (17.6)  
Weekly physical activity      < .0001
None 338 (15.0) 2209 (17.8)  
Light physical activity most weeks 1193 (53.1) 5902 (47.4)  
Vigorous physical activity for at least 20 min, 1-2 times/wk 349 (15.5) 2350 (18.9)  
Vigorous physical activity ≥20 min ≥3 times/wk 368 (16.4) 1994 (16.1)  

CAD, coronary artery disease.
Data are expressed as No. (%).

Table 3. Medical History

  Spain (n = 2257) Other countries (n = 12 469) P
Confirmed CAD      
Myocardial infarction 1430 (63.6) 6988 (59.1)  < .0001
PCI 1388 (61.7) 7692 (61.7) .9962
Revascularization surgery 433 (19.3) 3391 (27.2)  < .0001
Other      
Abdominal aortic aneurysm 54 (2.4) 306 (2.5) .8809
Carotid artery disease 121(5.4) 1087 (8.7)  < .0001
Implantable cardioverter-defibrillator 48 (2.1) 228 (1.8) .3263
Pacemaker 66 (3.0) 393 (3.2) .5836
Stroke 101 (4.5) 386 (3.1) .0007
Transient ischemic attack 75 (3.3) 413 (3.3) .956
Hospitalized for CHF 116 (5.2) 459 (3.7) .0009
Atrial fibrillation/flutter 203 (9.0) 1047 (8.4) .3268
Asthma/COPD 235 (10.5) 1166 (9.4) .0904

CAD, coronary artery disease; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; PCI, percutaneous coronary intervention.
Data are expressed as No. (%).

Table 4. Baseline Clinical Profile

  Spain (n = 2257) Other countries (n = 12 469) P
BMI, kg/m2 27.8 [25.7-30.5] 27.5 [25.1-30.4]  < .0001
Waist circumference, cm 99 [91-106] 99 [90-107] .9446
SBP, mean (SD), mmHg 131 (16) 131 (16) .3225
DBP, mean (SD), mmHg 76 (10) 77 (9)  < .0001
HR by pulse palpation, mean (SD), bpm 66 (11) 66 (11) .0018
HR on ECG, mean (SD), bpm 65 (11) 65 (11) .1046
ECG      
Sinus rhythm 1942 (93) 8881(94) .4721
Atrial fibrillation/flutter 95 (5) 387 (4)  
Paced rhythm 48 (2) 194 (2)  
LBBB 154 (7) 501(5) .0002

BMI, body mass index; DBP, diastolic blood pressure; ECG, electrocardiogram; HR, heart rate; LBBB, left bundle branch block; SBP, systolic blood pressure; SD, standard deviation.
Unless otherwise indicated, the data are expressed as No. (%) or median [interquartile range].

Table 5. Current Symptoms

  Spain (n = 2257) Other countries (n = 12 469) P
Angina 489 (21.8) 1565 (12.6)  < .0001
CCS I 161 (7.2) 561 (4.5)  < .0001
CCS II 283 (12.6) 760 (6.1)  
CCS III 43 (1.91) 211 (1.7)  
CCS IV 2 (0.1) 32 (0.3)  
CHF symptoms      
No symptoms 2084 (92.8) 11 581 (93.0) .8992
With NYHA II symptoms 137 (6.1) 729 (5.9)  
With NYHA III symptoms 26 (1.2) 147 (1.2)  

CCS, Canadian Cardiovascular Society class; CHF, congestive heart failure; NYHA, New York Heart Association functional class.
Data are expressed as No. (%).

Table 6 shows the treatment the patients were receiving at the time of the baseline visit. The most common treatments in the Spanish sample were lipid-lowering drugs (96%), aspirin (89%), and beta-blockers (74%). The greatest difference between Spain and the other western European countries was in the higher frequency of specific treatments such as ivabradine, antidiabetic agents, long-acting nitrates, and proton pump inhibitors in the Spanish cohort.

Table 6. Treatments

  Spain (n = 2257) Other countries (n = 12 469) P
Cardiovascular treatments      
Antiplatelet agents      
ASA 1994 (88.74) 10 477 (84.13)  < .0001
Thienopyridine 656 (29.27) 3184 (25.59) .0003
Other antiplatelet agents 202 (8.99) 939 (7.55) .0187
Anticoagulants 214 (9.52) 1191 (9.56) .9516
Beta-blockers 1659 (73.83) 9005 (72.31) .1373
Ivabradine 443 (19.72) 1440 (11.56)  < .0001
Calcium channel blockers 668 (29.73) 3065 (24.62)  < .0001
ACEI and/or ARB 1639 (72.94) 9419 (75.64) .0065
Lipid-lowering drugs 2148 (95.59) 11 535 (92.63)  < .0001
Long-acting nitrates 710 (31.6) 1989 (15.97)  < .0001
Other antiangina drugs 116 (5.17) 869 (6.98) .0016
Diuretics 651 (28.98) 3813 (30.62) .12
Other antihypertensive drugs 126 (5.61) 897 (7.2) .0064
Digoxin and derivatives 61 (2.71) 244 (1.96) .0208
Amiodarone/dronedarone 63 (2.80) 373 (3) .6221
Other antiarrhythmic drugs 15 (0.67) 137 (1.1) .0617
Other treatments      
NSAIDs 104 (4.64) 642 (5.16) .3025
Antidiabetic agents 682 (30.35) 2667 (21.42)  < .0001
Proton pump inhibitors 1279 (56.95) 4032 (32.38)  < .0001
THRT 69 (3.07) 772 (6.2)  < .0001
HRT in postmenopausal women 3 (0.13) 54 (0.43) .04
Treatment for erectile dysfunction 53 (2.36) 277 (2.22) .6936

ACEI, angiotensin-converting enzyme inhibitors; ARB, angiotensin II receptor antagonists; ASA, acetylsalicylic acid; HRT, hormone replacement therapy; NSAIDs, nonsteroid anti-inflammatory agents; THRT, thyroid hormone replacement therapy.
Data are expressed as No. (%).

DISCUSSION

The results of this study show that the sociodemographic and clinical characteristics of the stable CAD patients in the Spanish cohort of the CLARIFY registry are similar to those of patients in the other participating western European countries. These characteristics appear to be representative of the Spanish population with CAD, since they are generally similar to those reported by other studies that also included patients with CAD in both local4 and international settings.11, 12

More than half of the participants in the Spanish sample were men with a mean age of approximately 65 years, which is similar to the mean age previously observed in this population.4, 11, 13 Some significant differences were found between the Spanish cohort and the other cohorts, although in principle these differences were not expected. The observed difference in some demographic characteristics, such as age, may have been the result of minor differences of little importance but which became statistically significant due to the large sample size. The observed differences in educational level may have been partly due to differences in the way education systems are classified in each country. There were also unexpected differences in having a family history of CAD or DM. These differences may have been due to under-reporting by the cardiologists, rather than to a real difference between groups.

Tobacco consumption was low, and the percentage of smokers (9%) was similar to that reported in other Spanish registries on coronary heart disease.4, 13 The percentage of smokers was also slightly lower than in the other western European countries, a finding that has also been reported in other international registries that included Spanish patients with coronary heart disease.11, 13 Comparative studies conducted in Europe in CAD patients show a decrease in tobacco consumption in Spain over the last 10 years (18% in Spain vs 21% in Europe).14 This trend reflects a change in lifestyle among CAD patients in Europe; the need to decrease tobacco consumption has been demonstrated and remains a fundamental aspect for the secondary prevention of CAD.2

The pattern of other risk factors is consistent with that previously observed in this population.4, 11, 13, 14 Thus, the prevalence of DM in the Spanish cohort was similar to that observed in other registries11, 13, 14 and somewhat lower than that reported in patients with high cardiovascular risk.15, 16 The rate of hypertension was also similar to that reported in other studies11, 13 and lower than that observed in patients with acute CAD.16

Although the differences in clinical profile between the Spanish cohort and the western European cohorts in parameters such as body mass index, diastolic blood pressure and HR were statistically significant (P < .05) (Table 4), the absolute value of these differences was of no clinical relevance. The mean blood pressure in all the CLARIFY cohorts was within the range recommended by the clinical practice guidelines2 and was slightly lower than that recently observed in CAD patients in Europe.12 However, the average resting HR (65 bpm) in all the cohorts exceeded the recommended target rate (55-60 bpm).17 Recently published data from the entire CLARIFY registry show that an HR > 60 bpm was associated with a higher prevalence and greater severity of angina.9 These data indicate the need for improved treatment to reduce HR in patients with stable angina to the recommended target rate of 60 bpm.17

The most pronounced differences between the Spanish and European cohorts were related to specific treatments. Although demographic and clinical characteristics did not generally differ between cohorts, the differences observed in treatment could indicate different clinical practices in each country, thus underlining the need for an international registry similar to that presented here. Follow-up data from the registry are needed to understand the prognostic implications of these differences. To date, data from the baseline visit only show that there are specific differences in treatments between the Spanish and western European cohorts. These differences mainly involve the use of cardiovascular drugs such as ivabradine and long-acting nitrates, which were more frequently used in the Spanish sample (20% and 32%, respectively) than in the other European countries (12% and 16%, respectively). However, the observed difference in the use of antidiabetic agents (30% in the Spanish cohort and 21% in the other cohorts) could be explained by the higher prevalence of DM recorded in Spain (34% in Spain and 25% in other western European countries). Furthermore, the increased use of proton pump inhibitors in the Spanish cohort is striking compared with the other cohorts and with other treatments. Although the abuse of these drugs in Spain is well known,18, 19 the marked difference between Spain and the other countries cannot be explained by differences in age or in the use of medications that increase the risk of bleeding, since both factors are similar in both groups. In the absence of additional data on comorbidities that may be associated with this increase, it can only be speculated that the use of these drugs in Spanish clinical practice must strongly differ from their use in the other western European countries in the registry.

Overall, the pattern of use of cardiovascular drugs reported in the CLARIFY registry is similar to that previously reported for the Spanish population with CAD, with the exception of specific treatments such as beta-blockers and lipid-lowering drugs, whose use is slightly higher than that reported in similar registries.4, 11, 20 The number of prescriptions for beta-blockers is even higher than that previously observed in patients hospitalized with acute myocardial infarction.21 The clinical practice guidelines recommend beta-blockers in these patients and even in patients with type II diabetes. The widespread use of antiplatelet agents was similar to that observed in the total sample and to that published by other studies,4, 12 but was slightly higher than in other registries.20 The level of use is consistent with the clinical guidelines, which recommend antiplatelet therapy in all patients with CAD unless contraindicated.2 The cross-sectional design of the present study does not allow assessment of the degree of nonadherence with clinical practice guidelines in drug prescription and its possible causes; however, this information can be analyzed during follow-up of the registry, which, unlike previous registries,22 has the advantage that it will allow longitudinal and prospective data collection.

Furthermore, this prospective registry is ongoing and we expect to be able to construct a prediction model that includes factors such as DM, dyslipidemia, obesity23 and HR,3 with a demonstrated important prognostic role in the mortality rates of these patients. Finally, the CLARIFY registry will identify and provide patient cohorts that could be of interest to future clinical studies on improving the management of CAD. It would also be of interest to assess whether there are differences between specific subgroups, since there appear to be differences, for example, between men and women in the control of risk factors after an acute coronary episode24 despite their receiving similar treatment.24, 25

Strengths and Limitations

Some limitations should be considered when interpreting the results of this study, such as the use of convenience sampling rather than randomized sampling to select the centers and patients. The use of this method raises the issue of whether the sample is representative of the population under study. However, several aspects can be cited in favor of its representativeness, such as the large number of patients enrolled in the study and, in particular, the similarity of its results with those of other studies in this patient population. Despite these limitations, the registry has several strengths, including the large number of participating countries, making the results more generalizable. The CLARIFY registry is not restricted to a particular geographical area and provides information on daily clinical practice in stable CAD patients.

CONCLUSIONS

The baseline data provided by the CLARIFY registry indicate that the stable CAD patients in the Spanish sample appear to be representative of the Spanish population with CAD and are similar to stable CAD patients in other western European countries. The results of the 5-year follow-up will provide information on how these patients are managed in clinical practice and the degree of adherence to the recommendations of the clinical practice guidelines, leading to improvements in the treatment of this patient population.

FUNDING

Laboratorios Servier S.L.

CONFLICTS OF INTEREST

None declared.

Acknowledgements

In Spain, the CLARIFY registry was organized and managed by the Spanish Society of Cardiology via its Research Agency, which was funded by Laboratorios Servier S.L. Data analysis was conducted by the Robertson Centre for Biostatistics at Glasgow University, UK. We would like to thank Teresa Hernando (Cociente S.L.) for her assistance in writing this article.

Supplementary MATERIAL

PDF file

Received 7 June 2013
Accepted 21 October 2013

Corresponding author: Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Ctra. de Colmenar Km 9,100, 28034 Madrid, Spain. zamorano@secardiologia.es

Bibliography

1. European cardiovascular disease statistics 2008. European Heart Network;2008 [accessed 11 Oct 2011]. Available at: http://www.ehnheart.org/.
2. Perk J, De Backer G, Gohlke H, Graham I, Reiner Z, Verschuren M, et al. European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J. 2012;33:1635-701.
Medline
3. Diaz A, Bourassa MG, Guertin MC, Tardif JC. Long-term prognostic value of resting heart rate in patients with suspected or proven coronary artery disease. Eur Heart J. 2005;26:967-74.
Medline
4. Cordero A, Bertomeu-Martinez V, Mazon P, Quiles J, Aznar J, Bueno H. Differences in medical treatment of chronic coronary heart disease patients according to medical specialities. Cardiovasc Ther. 2009;27:173-80.
Medline
5. Daly CA, Clemens F, Sendon JL, Tavazzi L, Boersma E, Danchin N, et al. The clinical characteristics and investigations planned in patients with stable angina presenting to cardiologists in Europe: from the Euro Heart Survey of Stable Angina. Eur Heart J. 2005;26:996-1010.
Medline
6. Rationale and design of the GRACE (Global Registry of Acute Coronary Events) Project: a multinational registry of patients hospitalized with acute coronary syndromes. Am Heart J. 2001;141:190-9.
7. Bueno H, Bardají A, Fernández-Ortiz A, Marrugat J, Martí H, Heras M. Manejo del síndrome coronario agudo sin elevación del segmento ST en España. Estudio DESCARTES (Descripción del Estado de los Síndromes Coronarios Agudos en un Registro Temporal Español). Rev Esp Cardiol. 2005;58:244-52.
Medline
8. CLARIFY registry launched in South Africa. Cardiovasc J Afr. 2010;21:170.
9. Steg PG, Ferrari R, Ford I, Greenlaw N, Tardif JC, Tendera M, et al. Heart rate and use of beta-blockers in stable outpatients with coronary artery disease. PLoS One. 2012;7:e36284.
Medline
10. Fox K, Ford I, Steg PG, Tendera M, Robertson M, Ferrari R. Heart rate as a prognostic risk factor in patients with coronary artery disease and left-ventricular systolic dysfunction (BEAUTIFUL): a subgroup analysis of a randomised controlled trial. Lancet. 2008;372:817-21.
Medline
11. Esmatjes E, Blanco AJ. [The REACH registry: baseline and 1-year results]. Med Clin (Barc). 2009;132(Supl2):5-9.
Medline
12. Kotseva K, Wood D, De Backer G, De Bacquer D, Pyorala K, Keil U. EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. Eur J Cardiovasc Prev Rehabil. 2009;16:121-37.
Medline
13. Suarez C. Baseline characteristics of patients with cerebrovascular disease in the REACH registry: the Spanish contribution. Cerebrovasc Dis. 2007;24(Suppl 1):89-95.
Medline
14. Lifestyle and risk factor management and use of drug therapies in coronary patients from 15 countries;principal results from EUROASPIRE II Euro Heart Survey Programme. Eur Heart J. 2001;22:554-72.
15. de la Peña Fernández A, Suárez Fernández C, Cuende Melero I, Muñoz Rodríguez M, Garre Canovas J, Camafort Babkowski M, et al. [Integral control of risk factors in patients of high and very high cardiovascular risk in Spain, CIFARC project]. Med Clin (Barc). 2005;124:44-9.
Medline
16. Cabades A, Lopez-Bescos L, Aros F, Loma-Osorio A, Bosch X, Pabon P, et al. Variabilidad en el manejo y pronóstico a corto y medio plazo del infarto de miocardio en España: el estudio PRIAMHO. Rev Esp Cardiol. 1999;52:767-75.
Medline
17. Gibbons RJ, Abrams J, Chatterjee K, Daley J, Deedwania PC, Douglas JS, et al. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina—summary article: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee on the Management of Patients With Chronic Stable Angina). J Am Coll Cardiol. 2003;41:159-68.
Medline
18. deBurgos Lunar C, Novo del Castillo S, Llorente Diaz E, Salinero Fort MA. [Study of prescription-indication of proton pump inhibitors]. Rev Clin Esp. 2006;206:266-70.
Medline
19. Ramirez E, Lei SH, Borobia AM, Pinana E, Fudio S, Munoz R, et al. Overuse of PPIs in patients at admission, during treatment, and at discharge in a tertiary Spanish hospital. Curr Clin Pharmacol. 2010;5:288-97.
Medline
20. Gomez Cerezo JF. [Use of drugs in the REACH registry: from guidelines to clinical practice]. Med Clin (Barc). 2009;132(Supl2):44-6.
Medline
21. Aros F, Cunat J, Loma-Osorio A, Torrado E, Bosch X, Rodriguez JJ, et al. Tratamiento del infarto agudo de miocardio en España en el año 2000. El estudio PRIAMHO II. Rev Esp Cardiol. 2003;56:1165-73.
Medline
22. Roa L, Monreal M, Carmona JA, Aguilar E, Coll R, Suarez C. [Treatment inertia in secondary prevention of cardiovascular disease. FRENA registry]. Med Clin (Barc). 2010;134:57-63.
Medline
23. Prugger C, Keil U, Wellmann J, De Bacquer D, De Backer G, Ambrosio GB, et al. Blood pressure control and knowledge of target blood pressure in coronary patients across Europe: results from the EUROASPIRE III survey. J Hypertens. 2011;29:1641-8.
Medline
24. Dallongevillle J, De Bacquer D, Heidrich J, De Backer G, Prugger C, Kotseva K, et al. Gender differences in the implementation of cardiovascular prevention measures after an acute coronary event. Heart. 2010;96:1744-9.
Medline
25. Reina A, Colmenero M, Aguayo de Hoyos E, Aros F, Marti H, Claramonte R, et al. Gender differences in management and outcome of patients with acute myocardial infarction. Int J Cardiol. 2007;116:389-95.
Medline

1885-5857/© 2014 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved

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