| BackgroundWith the aging of the population and the average life expectancy increases,the prevalence of coronary heart disease and mortality rates were rising gradually.In recent years,research shows that there is a growing tendency of premature coronary heart disease.The cardiovascular risk factors may strongly influence the progression of atherosclerosis,so coronary artery disease occurred in early course of disease or have developed rapidly.There are few reports about the cardiovascular risk factors and the degree of atherosclerosis.These studies use the degree of coronary artery diseased as the aim,and used to quantify coronary artery disease through the numbers of narrowed vessels.There are few reports about the risk factors,quantify coronary artery disease,follow-up of clinical efficacy of premature coronary artery disease(CAD),and the results consistent failure.Clinical trials have demonstrated the efficacy of aspirin,β-blockers(BBs), angiotensin-converting enzyme inhibitors(ACEI)/angiotensin receptor blocker (ARB),and statins medications for secondary prevention of coronary artery disease (CAD).The ACC/AHA clinical practice guidelines recommendations these medications for patients with CAD to reduce recurrent cardiovascular events. However,prior studies have shown medication nonadherence is a common problem among outpatients with CAD,limiting the effectiveness of secondary ptevention medications.And little is known about the impact of nonadherence on outcomes of patients who undergone percutaneous coronary intervention(PCI) procedure.ObjectivesThis study was specifically designed to explore the cardiovascular risk factors and clinical feature of coronary lesions in the premature CAD patients and to determine clinical outcomes of nonadherence to evidence-based cardiovascular medications prescribed at hospital discharge at 1-year.Methods1.Study populationThe study was divided into three parts according to the cluster approach.1.1 The study population included hospitalized patients diagnosed through coronary angiography and underwent PCI treatment firstly in the cardiology department of NanFang Hospital from January 2000 to December 2007,622 patients to be selected(in the first part of the study).1.2 The study population included hospitalized patients diagnosed through coronary angiography and underwent PCI treatment firstly in the cardiology department of NanFang Hospital,Zhujiang Hospital which affiliated Southern Medical University,the cardiology department of Zhongshan City People's Hospital of Zhongshan Medical University from January 2007 to December 2007,692 patients to be selected.Major exclusive criteria were cardiac shock,serious diseases such as malignant tumor,serious kidney dysfunction which would influence patients' life expectation,patients whom diagnosed Disease of immune system or connective tissue diseases,and those lost to follow-up during 1 year.3 patients with cardiac shock,2 patient with serious kidney dysfunction,59 patients were lost to follow-up during 1 year in three hospitals above.64 patients were deplete,and 628 patients to be selected in the end(in the second part of the study).1.3 The study population included similar to the second part of the study.Major exclusive criteria were cardiac shock,serious diseases such as malignant tumor,serious kidney dysfunction which would influence patients' life expectation, patients whom diagnosed Disease of immune system or connective tissue diseases,those lost to follow-up during 1 year,and died or suffer from MI in hospitalization.3 patients with cardiac shock,2 patient with serious kidney dysfunction,59 patients were lost to follow-up during 1 year,and 4 patients died or suffer from MI in hospitalization.68 patients were deplete,and 624 patients to be selected in the end(in the three part of the study).According to the age,patients were divided into two groups.Patients(male＜55 years-old,female＜65 years-old)were defined premature CAD,Patients(male≥55 years-old,female≥65 years-old)were defined mature CAD.The patients were alive and free from MACE at hospital discharged were divided into two groups,the adheret group and the nonadheret group according to the medication adherence.2.Study method2.1 Risk factors identify:family history of ischemic cardiovascular disease, smoking,hypertension,type 2 diabetes mellitus,dyslipidemia,hemoglobin(HGB), total bilirubin(TB),plasma lipid,plasma uric acid(UA),plasma fibrinogen(Fib). The blood-fat include total cholesterol(TC),low density lipoprotein cholesterol (LDL-C),high density lipoprotein cholesterol(HDL-C) and triglyeride(TG).2.2 Coronary angiography:The professional medical doctor from the cardiology department finished the coronary angiography.CAD is defined as a coronary artery stenosis involving the main coronary artery,lesions≥50%.Coronary artery branch number is defined as the number of coronary stenosis≥50%involved a number of major coronary branch,divided into 0,1,2,3 vessel disease.Using Gensini cumulative index quantified the degree of vascular disease.Using Gensini cumulative index quantified the degree of vascular disease.According to the extent of the narrowed vessel:①≤25%score 1 point;②25%～＜50%score 2 point;③50%～＜75%score 4 point;④75%～＜90%score 8 point;⑤90%～＜99%score 16 point;⑥99%～100%score 32 point.The coefficient of each segment:①left main coronary artery×5;②the approaching segment of left anterior decending branch×2.5;③the middle segment of left anterior decending branch×1.5;④the gap of left circumflex branch×3.5;⑤the approaching segment of left circumflex branch×2.5;⑥the posterior branch of left ventricular×0.5;⑦the first and second diagonal branches,obtuse marginal branch,the distal segment of left anterior decending branch,the approaching segment and the middle segment and the distal segment of right coronary artery,posterior descending branch×1.The segment score is the score of each lesion multiply coefficient.The Gensini cumulative index of each patient is the sum of the all segment scores.2.3 Follow-upPatients were evaluated at 1 year after the stent implantation procedure and at hospital discharge,follow-up information was obtained by telephone or outpatient interview.We selected 4 medications:aspirin,BBs,ACEI/ARB,and statins which based on AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease:2006 Update and examined adherence to these medications by comparing baseline prescription at hospital discharge to self-reported information at 12 months.Patients were classified as "adherent" if they were taking a regimen during 1 year follow-up which was similar to that recommended at hospital discharge.Patients were adherent if they continued all medication classes they were prescribed at discharge.Adherence was measured for each individual therapy and as an overall composite(continuation of all of the baseline therapies).2.4 Study end pointThe composite end point was the occurrence of major adverse cardiac events (MACE) during 1 year.MACE was defined as a composite of cardiac death,non-fatal myocardial infarction(MI),and target vessel revascularization(TVR).Recurrence of chest pain symptoms or new ECG changes accompanied by the serum cardiac enzymes increased 2 times higher than the normal standard was defined non-fatal MI.3.Statistical analysesThe SPSS statistical package for Windows version 13.0 was used for the statistical analysis.Continuous variables were expressed as mean value±standard deviation(mean±SD),and the comparison between groups was made using 2 independent-samples t or t' test;Categorical variables were by number(%),the chi-square test was used to compared categorical variables;Logistic regression was used to multiplicity analysis.A P value≤0.05 was considered statistically significant.Results1.Study on the cardiovascular risk factors and coronary lesions of patients with premature coronary artery disease after PCI --Part one of studyThe population included in the analysis consisted of 622 patients:221 were premature CAD group,and 411 were mature CAD group.Baseline clinical characteristics were comparable,except that premature CAD group patients had more the family history of ischemic cardiovascular disease(P = 0.000),the history of smoking smoking(P=0.005),less hypertension(P=0.017) compared with mature CAD group patients(Table 1-1).The blood biochemistry indexes of patients revealed several differences between the 2 groups(Table 1-2).The level of triglyceride(TG)(P = 0.000), hemoglobin(HGB)(P = 0.000) and plasma fibrinogen(Fig)(P= 0.000) in premature CAD group were significant higher than those of mature CAD group,and the level of plasma uric acid(UA)(P=0.004) was lower than mature CAD group. The other biochemistry indexes in the distribution of statistic were not significant in the two groups.Logistic regression was used to multiplicity analysis of premature CAD(Table 1-3):The major risk factors of premature CAD were the family history of ischemic cardiovascular disease,hypertriglyceridemia,HGB and Fig.The characteristic of coronary artery diseased(Table 1-4):The proportion of the single coronary artery in premature CAD group was higher than mature CAD(P = 0.000);the proportion of the left circumflex branch(LCX)(P = 0.000),the right coronary artery(RCA)(P=0.000) in premature coronary artery disease patients were lower than mature CAD.The degree of coronary artery disease was comparable by Gensini cumulative index(Table 1-5):The CAD Gensini cumulative index of the fourth group(P = 0.038) and the fifth group(P=0.011) in premature coronary artery disease patients were lower than mature CAD in the CAD Gensini cumulative index in the five groups.2.Study on the cardiovascular risk factors and coronary lesions of patients with premature coronary artery disease and the One-year follow-up after PCI in NanFang Hospital,Zhujiang Hospital which affiliated Southern Medical University,the cardiology department of Zhongshan City People's Hospital of Zhongshan Medical University--Part two of studyBased on the above criteria,229 were premature CAD,and 399 were mature CAD.Baseline clinical characteristics were comparable,except that the family history of ischemic cardiovascular disease(P=0.000) and the history of smoking(P =0.000),less hypertension(P=0.000) compared with mature CAD group patients (Table 2-1).The blood biochemistry indexes of patients revealed several differences between the 2 groups(Table 2-2).The level of triglyceride(TG)(P=0.000), hemoglobin(HGB)(P=0.000) and plasma fibrinogen(Fig)(P=0.000) in premature CAD group were significant higher than those of mature CAD group,and the level of plasma uric acid(UA)(P=0.004) was lower than mature CAD group. The other biochemistry indexes in the distribution of statistic were not significant in the two groups.Logistic regression was used to multiplicity analysis of premature CAD(Table 2-3):The major risk factors of premature CAD were the family history of ischemic cardiovascular disease,the history of smoking,hypertriglyceridemia,HGB and Fig.The characteristic of coronary artery diseased(Table 2-4):The proportion of the single coronary artery in premature CAD group was higher than mature CAD(P = 0.000);the proportion of the left circumflex branch(LCX)(P=0.006),the right coronary artery(RCA)(P=0.014) in premature coronary artery disease patients were lower than mature CAD.The degree of coronary artery disease was comparable by Gensini cumulative index(Table 2-5):The CAD Gensini cumulative index of the fourth group(P= 0.013) and the fifth group(P=0.004) in premature coronary artery disease patients were lower than mature CAD in the CAD Gensini cumulative index in the five groups. 4 patients died or suffer from MI in hospitalization,so 624 patients to be selected.During 1 year follow-up,the accumulated incidence of MACE and all-cause death in mature CAD patients group was significantly higher than that of premature CAD patients group(P = 0.039,P = 0.040,respectively),and the adherence of premature CAD patients group was significantly higher than that of mature patients CAD(P=0.001).The two study groups did not differ significantly in the composite of cardiac death(P=0.437),non-fatal MI(P=0.259) and TVR(P =0.052)(Table 2-6).3.Study on the One-year follow-up of medication adherence after PCI in NanFang Hospital,Zhujiang Hospital which affiliated Southern Medical University,the cardiology department of Zhongshan City People's Hospital of Zhongshan Medical University--Part three of studyThe population included in the analysis consisted of 624 patients:229 were premature CAD group,and 395 were mature CAD group;466 were adheret group, and 158 were nonadheret group.At discharge,aspirin was prescribed in 98.3%,BBs in 63.3%,ACEI/ARB in 58.1%,and statins in 93.9%among premature CAD patients.The proportion of patients who adherent to aspirin,BBs,ACEI/ARB,and statins was 94.7%,91.0%, 85.0%,and 86.0%,respectively.Adherence was highest for aspirin(Table 3-1).At discharge,aspirin was prescribed in 96.5%,BBs in 52.7%,ACEI/ARB in 68.9%,and statins in 95.2%among mature CAD patients.The proportion of patients who adherent to aspirin,BBs,ACEI/ARB,and statins was 93.2%,82.2%,77.6%,and 81.1%,respectively.Adherence was highest for aspirin(Table 3-2).At discharge,the proportion of patients who use of 1-,2-,3-,and 4-type of drugs was 0.4%,20.5%,43.7%,and 35.4%,respectively.During 1-year follow-up, the proportion of patients who use of 1-,2-,3-,and 4-type of drugs was 5.7%,27.1%, 34.5%,and 30.1%,respectively(Table 3-3).At discharge,the proportion of patients who use of 1-,2-,3-,and 4-type of drugs was 0.5%,19.2%,45.8%,and 34.4%,respectively.During 1-year follow-up, the proportion of patients who use of 1-,2-,3-,and 4-type of drugs was 7.6%,29.6%, 37.0%,and 22.3%,respectively(Table 3-4).During 1-year follow-up,the accumulated incidence of MACE and TVR in adheret group was significantly lower than that of nonadheret group(P = 0.001,P = 0.006,respectively).The two study groups did not differ significantly in the composite of cardiac death(P = 0.073),non-fatal MI(P=0.283)(Table 3-5).Conclusion1.The family history of ischemic cardiovascular disease,the history of smoking, the level of triglyceride(TG),hemoglobin(HGB) and plasma fibrinogen(Fig) are risk factors of premature CAD patients.2.The patients with premature CAD had higher proportion in single vessel lesion and slight lesion comparing with mature CAD patients.3.The adherence of premature CAD patients was better than mature CAD patients.The rate of MACE and all-cause death in premature CAD patients was lower than mature CAD patients.
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