Atherothrombosis is the underlying pathology for most ischaemic events, including myocardial infarction, many forms of stroke, peripheral arterial insufficiency, and cardiovascular death, together with sudden cardiac death. As such, atherothrombosis represents a major healthcare concern throughout the world. Due to the increase in sedentary lifestyle and overeating, obesity, metabolic syndrome, and diabetes are all increasing in parallel, fuelling the atherothrombosis epidemic. It is likely, as the population ages and as urbanisation and industrialisation continue, that atherothrombosis will grow in prominence as a major public health problem.
In this larger context, the international Reduction of Atherothrombosis for Continued Health (REACH) Registry was launched in order to study outcomes of atherothrombotic disease, risk factors for atherothrombosis, and also current treatment patterns. Already, the REACH Registry has provided insights at a global level.1 For example, under-treatment of common risk factors such as hypertension, hyperlipidaemia, and diabetes was observed in all regions included in the REACH Registry. Obesity, including morbid obesity, was highly prevalent. Multivascular disease – atherothrombosis affecting more than one arterial territory – was present in approximately 15% of patients. These insights have added greatly to our appreciation of atherothrombosis.
High event rates shown at one year
What are the consequences of these findings? The one-year event rates in the global REACH database were seen to be quite high.2 These presumably stable out-patients had an extraordinarily high chance of sustaining an ischaemic event or a hospitalisation over the ensuing year of follow up. Patients with multivascular disease, in particular, had a worse outcome, with greater arterial involvement associated with even higher rates of ischaemic events. Thus, it would be an error for the physician caring for the stable patient with atherothrombosis to be lulled into a false sense of security. A patient with atherothrombosis remains at high risk of further ischaemic events. Aggressive risk reduction methods are necessary.
The UK REACH investigators are to be congratulated for a successful execution of the REACH Registry in their region. A great deal of planning and effort went into REACH in the UK. The publication in this issue of REACH data from the UK cohort (see pages 215–18) is important on several levels.3
First, it affirms the observations regarding the consequences of under- treatment that were seen in the global analysis. Hopefully, this will serve as a call to action to UK physicians regarding their patients with evident atherothrombosis or at high risk for the condition. In a sense, the timing could not be better. With the institution of pay for performance measures in UK primary care, there is now a greater appreciation of the need for quality improvement, but also an acknowledgement that such initiatives require resources to implement.
Second, the spirit of REACH right from the start has been one of international collaboration and good will. By participating in REACH, the UK is part of a global medical and scientific undertaking, which aims to fundamentally improve patient care. The beneficiaries of this participation will be patients (and doctors) in both the UK, as well as throughout the world, who will gain further insights into atherothrombosis and how best to treat this prevalent condition.
Conflict of interest
DLB and PGS were principal investigators in the REACH Registry, which was funded by Sanofi-Aventis, Bristol-Myers Squibb, and the Waksman Foundation. DLB has received honoraria and/or acted as consultant/advisory board member for AstraZeneca, Bristol-Myers Squibb, Cardax, Centocor, Cogentus, Daiichi-Sankyo, Eisai, Eli Lilly, GlaxoSmithKline, Johnson & Johnson, McNeil, Medtronic, Millennium, Otsuka, Paringenix, PDL, Sanofi-Aventis, Schering Plough, The Medicines Company, tns Healthcare, and Vertex. He has also provided expert testimony regarding clopidgrel (compensation was donated to a non-profit organisation). PGS has served as a member of the speakers’ bureau and/or as a consultant/advisory board member for AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, GlaxoSmithKline, Merck Sharp & Dohme, Nycomed, Sanofi-Aventis, Servier and Takeda.
- Bhatt DL, Steg PG, Ohman EM et al. International prevalence, recognition and treatment of cardiovascular risk factors in outpatients with atherothrombosis. JAMA 2006;295:180–9.
- Steg PG, Bhatt DL, Wilson PWF et al. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007;297:1197–1206.
- Morrell JM, Kassianos GC. One-year data from the UK arm of the REACH Registry. Br J Cardiol 2007;14:215–18.