Systematic detection of polyvascular disease combined with aggressive secondary prevention in patients presenting with severe coronary artery disease: The randomized AMERICA Study.
BACKGROUND
The prevalence and associated-risk of asymptomatic multisite artery disease (MSAD) in high risk coronary patients are unknown. Whether systematic identification and aggressive management of asymptomatic MSAD is clinically relevant in high risk coronary patients has not been evaluated.


METHODS
We randomly assigned 521 high risk coronary patients defined by the presence of three-vessel coronary disease (n=304) or recent acute coronary syndrome beyond the age of 75years (n=215) to either a strategy of systematic detection of asymptomatic MSAD combined with an aggressive secondary prevention (n=263) or to a more conventional strategy based on treatment of coronary artery disease only with standard of care (n=258). The primary end point was the time to first occurrence of death, any organ failure or ischemic event leading to re-hospitalization through two years of follow-up.


RESULTS
The pro-active strategy identified asymptomatic MSAD in 21.7% of patients with few revascularizations (3.6%); the pro-active pharmacological secondary prevention was obtained in >85% of patients and life-style changes in <60% of patients. At 2-year follow-up, the primary end point occurred in 44.9% of patients in the pro-active group and 43.0% of patients in the conventional group (HR 1.03; 95% confidence interval [CI], 0.80 to 1.34]. The rate of major bleeding did not differ significantly between groups (4.6% vs 5.0%; HR, 0.97; 95% CI, 0.40 to 1.91).


CONCLUSION
In high risk coronary patients, there is no apparent benefit of a systematic detection of asymptomatic extra-coronary atherothrombotic disease and intensified treatment over a 2-year follow-up period. (Funded by the Academic Allies in Cardiovascular Trials Initiatives and Organized Networks and Institut de l'Athérothrombose; AMERICA ClinicalTrials.gov number, NCT00445835).
['Collet|Jean-Philippe|JP|', 'Cayla|Guillaume|G|', 'Ennezat|Pierre-Vladimir|PV|', 'Leclercq|Florence|F|', 'Cuisset|Thomas|T|', 'Elhadad|Simon|S|', 'Henry|Patrick|P|', 'Belle|Loic|L|', 'Cohen|Ariel|A|', 'Silvain|Johanne|J|', 'Barthelemy|Olivier|O|', 'Beygui|Farzin|F|', 'Diallo|Abdourahmane|A|', 'Vicaut|Eric|E|', 'Montalescot|Gilles|G|', '|||']
D000368:Aged D000369:Aged, 80 and over D003324:Coronary Artery Disease D004359:Drug Therapy, Combination D005260:Female D005500:Follow-Up Studies D005602:France D006801:Humans D008297:Male D008875:Middle Aged D062645:Percutaneous Coronary Intervention D010975:Platelet Aggregation Inhibitors D012307:Risk Factors D040242:Risk Reduction Behavior D055502:Secondary Prevention D012720:Severity of Illness Index
Coronary artery disease Atherothrombosis Myocardial infarction