Cardiovascular diseases (CVDs) and coronary artery disease (CAD) are still the leading causes of death both globally and in Brazil. The World Health Organization (WHO) estimated that ischemic heart disease and strokes, combined, caused more than 25% of deaths worldwide in 2019.¹ In Brazil, CAD remains the leading cause of death, with nearly 2% prevalence in the population, being responsible for 12% of deaths in 2019.² In comparison, CVD accounts for approximately 30% of death causes.³

Identifying individuals with atherosclerosis is crucial for establishing treatment and secondary prevention measures by assessing the risk of atherosclerotic disease. CAD probability results from variables such as the characterization of chest pain, sex, comorbidity, and age of the patient. Factors such as smoking (minimum of 25 pack-years), total cholesterol (> 250 mg/dL), and fasting blood glucose (> 140 mg/dL) also increase the risk of CAD.³

It is understood that cardiovascular risk factors such as systemic arterial hypertension (SAH), diabetes mellitus, dyslipidemia, smoking and obesity are potentially modifiable. Their lack of control is associated with worse cardiovascular outcomes and higher mortality; therefore, the management of these factors is essential in terms of prevention.^3-5 Likewise, the control of risk factors and the drug treatment of CAD bring clear benefits in reducing mortality rates.^3,4

This study was designed in line with the Survey of Risk Factor Management (SURF) trial^6,7 and EUROASPIRE^8,9 studies, which collect data on demographics, risk factors, and comorbidity management in CAD patients. While the SURF study is ongoing, previous publications have reported data from a pilot project and an audit involving 11 European countries,⁷ similar to the data collected in this study.

Therefore, Thus, this research aimed to evaluate the epidemiological status and prevalence of risk factors in CAD patients. Additionally, the study aimed to audit comorbidity records and assess the achievement of targets related to CAD risk factors, as well as to evaluate the quality of risk factor management and treatment for the selected patients.

This is an epidemiological, observational and cross-sectional study. Using a data collection form, patients treated at the Cardiology outpatient clinics of a Tertiary Hospital were selected. The inclusion criteria were patients treated during 2022, over 18 years of age, of both sexes, with CAD proven by one of the following criteria: a) Acute Coronary Syndrome (ACS); b) Stable Angina with typical alteration of Electrocardiogram, exercise test suggesting ischemia, positive scintigraphy for ischemia or lesion greater than or equal to 70% in one or more coronary arteries, as evidenced by coronary angiotomography or coronary cineangiography.

The information was collected by consulting the patients' electronic medical records without direct contact or new interference, all of which are presented in Table 1. The data were compiled into a Microsoft Excel spreadsheet and analyzed by calculating percentages, averages, and standard deviations.

The blood pressure and lipid profile variables were classified according to the targets established in the Cardiovascular Prevention Guideline.⁴ Thus, the blood pressure target adopted was systolic blood pressure (SBP) < 130mmHg and diastolic blood pressure (DBP) < 80mmHg. There is also a recommendation to avoid SBP < 120mmHg and DBP < 70mmHg, especially DBP < 60mmHg, due to the risk of coronary hypoperfusion. Regarding the lipid profile, the target was considered to be total cholesterol < 190, HDL > 40, triglycerides < 150, and LDL < 50.

For targets related to Diabetes, the Brazilian Diabetes Guidelines¹⁰ were used, establishing it at HbA1c < 7.0% for individuals in any age group, aiming to prevent long-term macrovascular complications as long as there is no risk of severe and frequent hypoglycemia. For elderly individuals with diabetes and CVD, less strict glycemic targets may be considered, such as an HbA1c between 7.0 and 7.5%. The diagnosis of Metabolic Syndrome was established based on the NCEP-ATP III criteria, as cited by the I Brazilian Guideline for Diagnosis and Treatment of Metabolic Syndrome.¹¹

Body mass index (BMI) was calculated according to the definitions of the WHO and the Brazilian Obesity Guidelines,¹² which classify Underweight for BMI < 18.5 kg/m², Normal Weight from 18.5 to 24.9 kg/m², Overweight from 25 to 29.9 kg/m², Obesity grade I from 30 to 34.9 kg/m², Obesity grade II from 35 to 39.9 kg/m², and Severe Obesity ≥ 40 kg/m². The European¹³ and North American¹⁴ Guidelines for the Prevention of CVDs established targets very similar to those of the Brazilian guidelines. Therefore, these were used to define the targets in this study.

The collected data allowed for the determination of the sample's epidemiological profile, including the prevalence of risk factors (such as hypertension and obesity) and whether targets were met or not (based on established guidelines). Moreover, the portion of the study population that received prescriptions for the classes of medications indicated in the CAD guidelines was determined.

The project for this research was submitted to the local Ethics Committee and approved under number CAAE 61589422.4.0000.0107, in compliance with the terms of resolution 466/2012 of the Brazilian National Health Council.

This article replicated the model proposed by the multicenter study SURF,^6,7 applying data collection form to the medical records of patients with CAD. This model is easily replicated in different centers, thus facilitating the mapping and management of risk factors in outpatients, in addition to allowing the auditing of data from the service itself and assessing the quality of medical records information. In this sample, the application process proved to be straightforward and efficient, similar to the SURF⁶ study, as it involved only reviewing medical records without needing to contact patients for additional consultations.

Given the same model, this study can be compared to the SURF^6,7 studies, as well as to similar studies found in the literature, such as the EUROASPIRE.^8,9 The identified demographic and epidemiological profile reflects the reality of a public tertiary hospital in southern Brazil, with a predominance of a white population with low levels of education since more than half of the sample had completed elementary school at most. This profile contrasts with the population studied in SURF, which included private patients – 12% in the European sample and 37% in the Asian sample – and also had a higher level of education.

The mean age found was similar to published SURF studies, as well as to a Brazilian study using the same model.¹⁵ The age range in these studies is slightly higher than the average of the EUROASPIRE studies and another national study carried out in Intensive Care Units.¹⁶ The proportion of men in our sample was lower than that found in the SURF and Mertins et al.¹⁶ studies (61.7% vs. 70.8 and 81.2%, respectively).

The main reason for outpatient follow-up was ACS, similar to the SURF studies^6,7 (63.9% of cases), with a predominance of treatment by PCI (58.3%), and almost half of the patients (42.4%) were hospitalized in the last year due to CAD. This finding reflects the Hospital's profile, which is currently the reference in ACS care in the region for the Brazilian Unified Health System. International studies^6,7 have found a 29% to 50% hospitalization rate in the last year due to CAD.

Regarding follow-up, approximately 67% of patients had been seen in the past 3 months, and nearly 75% had recent laboratory test results (including lipid profiles, fasting blood glucose, and hemoglobin A1c from the past year) in their medical records. This situation reflects the limitations of the public health system and the overcrowding of specialty outpatient clinics like ours. However, it indicates that medical care and management of comorbidities are below expectations due to infrequent consultations and a lack of diagnostic tests. This hinders effective interventions for reducing cardiovascular risk, such as managing underdiagnosed diabetes or prescribing statins for potential dyslipidemia.

Similar to other studies, a high prevalence of modifiable risk factors associated with increased cardiovascular risk is evident. Table 8 compares the prevalence of risk factors between national and international multicenter studies and the present study.

The Brazilian Guideline for Cardiovascular Prevention4 advocates for smoking cessation counseling and intensive treatment (grade IA recommendation), as well as counseling for physical activity and weight loss, emphasizing moderate to vigorous exercise due to its proven reduction in cardiovascular risk (grade IA recommendation). Additionally, it recommends intensive management of dyslipidemia, hypertension, and diabetes to mitigate cardiovascular event risk. The INTERHEART¹⁷ study found a clear link between individual and cumulative risk factors and a higher incidence of acute myocardial infarction, with current smoking and dyslipidemia being the primary factors. This study suggests that controlling modifiable risk factors could prevent most myocardial infarctions.

In this study, only 5.7% of patients had an LDL level < 50, and just 24.8% had an LDL level < 70. These LDL control rates are significantly lower than those reported in similar studies. European and Asian studies (SURF and EUROASPIRE^6-9) reported LDL within the target for 48.9% to 66% of patients, even using a stricter LDL target of < 45.

The main reason for this divergence involves the characteristics of the service evaluated. The hospital where this research was conducted reopened its hemodynamics service throughout 2022, with full operation starting only in June. Since then, it has become the local tertiary referral center for ACS. As a result, most outpatients were newly diagnosed with CAD following an ACS event, attending their first outpatient consultation after hospitalization. Given that many patients were treatment-naïve, the poor LDL control observed may be partly due to significant sampling bias. Several factors contributed to this issue, including the limited availability of Simvastatin in primary health care, difficulties in acquiring Atorvastatin through specific protocols, the low sociocultural level of the population, dietary habits, sedentary lifestyle, and poor medication adherence.

For arterial hypertension, the BP target was achieved in 10% of patients when considering the strict range specified by the Brazilian Guideline. However, this target was met in 59.6% of cases when using the BP threshold of < 130/80 mmHg, which is the reference used by other studies. Thus, SAH control was similar to the SURF^6,7 (39% to 60%) and EUROASPIRE^8,9 (44%) studies. It is also important to note that a significant number of patients had BP readings below the levels recommended by the guidelines. Approximately 38.7% of patients had SBP < 120mmHg, while 22.6% had DBP < 70mmHg, in addition to 2.2% with DBP < 60mmHg. Excessive SAH treatment, with a significant reduction in blood pressure values (mainly DBP), appears to be related to lower coronary perfusion, which can precipitate coronary events in patients with CAD.¹⁸

Regarding diabetes control, HbA1c was within target for 50.8% of diabetic patients, compared to 39-56% in the SURF^6,7 studies and 34.7% in EUROASPIRE^8,9 (the latter, however, considered a strict target of HbA1c ≤ 6.5).

With regard to the treatment of CAD and its risk factors, adequate prescriptions were found for most patients, with better percentages when compared to other studies, which again raises the hypothesis of the probable low medication adherence of the sample. While 93.9% of patients used antiplatelets and 100% used statins, the SURF^6,7 and EUROASPIRE^8,9 revealed they found rates between 80.8% and 95.1% of antiplatelet use and between 62% and 85% for statin use.

The use of ACE inhibitors or ARBs was found in 93.5% of our sample, compared to 47% to 78% in international studies.^6-9 Beta-blockers were prescribed to 93.5% of the patients evaluated, while SURF^6,7 and EUROASPIRE^8,9 reported a prescription of this drug class for 47% to 82.5% of participants. Most patients with diabetes were receiving treatment with oral hypoglycemic agents and/or insulin, and only 7 diabetic patients (7.1%) were not receiving treatment.

In addition to the poor control of risk factors, there were numerous failures in recording data relevant to the treatment of CAD and associated comorbidities. The medical records failed to indicate a history of smoking in 10% of cases, the level of physical activity and data for calculating BMI in approximately 70% of the records. Furthermore, a quarter of the patients did not have up-to-date laboratory tests due to a lack of a lipid profile, and a third of the diabetic patients did not have recent HbA1c monitoring.

Therefore, the numerous failures in recording and collecting laboratory tests are major limitations of the work, which can be explained by the lack of adequate guidance, medical requisition at hospital discharge, patients’ understanding, as well as scheduling errors by the administrative team. This potentially led to several prevalences being underestimated, including smoking, obesity, frequency and intensity of physical activity. The assessment of dyslipidemia and diabetes management targets may not fully reflect the actual situation. It is worth noting that SURF⁷ also indicated an approximately 10% overall failure rate of recordings.

In addition to recording errors, other limitations include the lack of standardization in laboratory tests and consultation data collection, such as blood pressure measurements. Isolated BP measurements during consultations can lead to inaccurate treatment prescriptions due to factors such as missed medication on the day of the visit or white coat hypertension. Moreover, the study population may not be highly representative, as it consists primarily of patients from a tertiary hospital, most of whom were discharged after an ACS.

The model developed in this study is user-friendly and has enabled the evaluation of risk factor prevalence as well as the self-assessment of data recorded in medical records. This approach has provided a comprehensive mapping of the patients attending the Cardiology outpatient clinics at our hospital, facilitating the development of targeted solutions and strategies tailored to this population.

However, the study identified numerous recording errors, underscoring the need for a standardized approach to medical record documentation. This would improve record accuracy and, thus, better manage and control risk factors.

The observed poor control of risk factors highlights the necessity for effective interventions. Since CAD is largely preventable with effective risk factor management, it is crucial to focus on lifestyle changes, medication adherence, and achieving treatment goals.