Regional and practice variation in adherence to guideline recommendations for secondary and primary prevention among outpatients with atherothrombosis or risk factors in the United States: A report from the REACH registry

Background: To reduce atherothrombosis-related morbidity and mortality, implementation of guideline-recommended therapies for primary and secondary prevention is necessary. Few data are available for outpatients in actual clinical practice, especially those without known heart disease treated by physicians trained in different specialties across the geographic regions of the United States. Methods: The REduction of Atherothrombosis for Continued Health (REACH) Registry compiled data on atherosclerosis risk factors and treatment in an office-based setting. A total of 25,686 outpatients in the United States aged ≥45 years with either established atherothrombotic disease (n = 19,069) or ≥3 atherosclerosis risk factors (n = 6617) were enrolled between 2003 and 2004. Preventive medication use was analyzed according to the geographic region and specialty of the treating physician. Results: Across the United States, 82% of patients with known disease were receiving at least 1 antiplatelet therapy, 83% were receiving a lipid-lowering agent, 65% were receiving an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ARB), and 57% were receiving a β-blocker; only 65% were on ≥3 of 4 of these classes of medications. For primary prevention, 62% were taking at least 1 antiplatelet agent, 77% were receiving a statin, 75% were receiving an angiotensin-converting enzyme inhibitor or ARB, and 79% were receiving ≥2 of 3 of these classes of drugs. Among physician specialties, cardiologists had the highest rates of prescribing ≥3 of 4 major classes of secondary prevention and ≥2 of 3 classes of primary prevention medications. Regionally, the Northeast had the highest and the South the lowest rates of utilization of prevention medications. Conclusions: Adherence to guideline-recommended preventive therapies in the outpatient setting was affected by patient characteristics, geographical region, and treating physician specialty. Novel approaches may be needed to improve the use of evidence-based, guideline-recommended therapies in these outpatient settings.