First PCIs Preceded by Many Modifiable Risk Factors: Registry Data

The majority of individuals with symptomatic CAD undergoing PCI for the first time have a high prevalence of modifiable CV risk factors, registry data suggest. Obesity and smoking, in particular, are associated with an earlier age of presentation for intervention among both men and women.

“Smokers versus nonsmokers presented about a decade earlier in this cohort of people undergoing their first PCI, and among obese patients with a [body mass index] greater than 30, it was about 4 years earlier,” senior author Devraj Sukul, MD, MSc (University of Michigan Health System, Ann Arbor), told TCTMD. “These effects appear to be additive and, probably even more importantly, smoking is a risk factor that's completely preventable.”

The study was published last week in PLoS ONE.

Of the more than 100,000 patients included in the PCI registry, 55.2% of women and 48.7% of men had three or more risk factors at the time of their procedure. The most common were hypertension (71.9%), dyslipidemia (65.1%), obesity (44.9%), current/recent smoking (34.5%), and diabetes (27.8%).

Commenting on the study for TCTMD, Vera Bittner, MD (The University of Alabama at Birmingham), said the study reinforces the notion that risk factors and overall CV risk should be assessed during patient encounters, that lifestyle counseling should be universal, and that pharmacologic therapy should be considered according to CV risk and patient preference. “It also reinforces the notion that primary prevention through lifestyle is very important,” she said in an email.

Risk Factors and Age Correlation

Sukul and colleagues led by Zoya Gurm (Wayne State University School of Medicine, Detroit, MI), used the Blue Cross Blue Shield of Michigan cardiovascular collaborative (BMC2) clinical PCI registry to look at risk factor prevalence and trends in patients with no history of MI or revascularization who underwent a first PCI at one of 47 hospitals in Michigan between 2010 and 2018. Of the more than 250,000 procedures performed, only 3.4% of women and 5.1% of men had no traditional CV risk factors. The average number of risk factors for the entire cohort was 2.5.

Smoking and obesity were more prevalent in younger patients. Among those age 45 or younger, 66% of women and 62% of men reported current/recent smoking compared with about 20% of men or women age 66 to 75. Likewise, in patients age 45 or younger, 62% of women were obese as were 57% of men, compared with 50% of women and 42.6% of men age 66 to 75. The reverse was true for hypertension, however, which was higher among those over age 75 (89% of women and 83.6% of men) compared with patients < 45 years old (62.3% of women and 56.4% of men).

Men and women with versus without acute MI were more likely to be smokers. There also was a trend toward greater smoking and obesity in younger versus older acute MI patients that mirrored the overall results.

Women typically presented at a later age then men, as other studies have shown. However, as the number of risk factors increased, the average age at presentation decreased regardless of sex: from 68.9 years for women with two risk factors to 57.2 years if they had five risk factors, and from 63 years for men with two risk factors to 56.6 years if they had five risk factors. Higher numbers of risk factors also narrowed the gap in mean age between men and women at presentation, such that for those with five risk factors there was little difference in age at first PCI.

“This information should change how not only cardiologists and interventional cardiologists, but frankly all practitioners including primary care physicians are talking to patients about their risk factors,” Sukul said. “I think we're all tasked with a really challenging burden of trying to address all these risk factors.”

Given how young many of these patients were when they presented for first PCI and the numbers who smoked and/or were obese, Sukul said there should be an emphasis on using the data in discussions with patients to increase understanding about the potential for delaying disease onset and the need for PCI.

Bittner added that risk-factor modification should be emphasized equally in men and women, and it should start as early as possible.

“Both women and men should eat better, control their weight, get regular physical activity, avoid smoking and, if they have risk factors such as diabetes or hypertension or hyperlipidemia, make sure that the risk factors are as well controlled as possible,” Bittner said. “Prevention should ideally start in the pediatric age group and there shouldn't be any differences in counseling between girls and boys. These preventive efforts should be continued throughout adult life.”