27th Bethesda Conference: matching the intensity of risk factor management with the hazard for coronary disease events. Task Force 8. Organization of preventive cardiology service

[Coronary risk and prescription in primary care patients with hypercholesterolemia]

OBJECTIVE

In patients with hypercholesterolaemia determinate the prevalence of high coronary risk (CR), study the lipid lowering treatment applied and determinate if there is any change in CR after a period of treatment.

DESIGN

Cross-sectional.

EMPLACEMENT

Primary care.

PATIENTS

583 patients with hypercholesterolaemia both sex, older than 25 years registered in chronic mobility, randomized selected.

MEASUREMENT AND RESULTS

Applying the Framingham coronary multivariate risk method we estimate high CR > 20%. Patients with a previous history of cardiovascular event, were treated in a 50%, more frequently younger subjects, rising 220 mg/dl of final cholesterol level. Patients without any cardiovascular event known, the 32.5% (28.0-36.7%) have a CR > 20%. Subjects with high CR have 4.9 (3.0-8.2) more probability if receiving treatment than the others with lower risk. The lipid-lowering treatment is explained in a 67% because the high CR and the family history of coronary event. After at least one year period there is a reduction in those with high CR (difference relative of proportions 28.7% [20.4-37.1]).

Aspirin use is low among United States outpatients with coronary artery disease

BACKGROUND

The goal of the present study was to assess national trends and patterns of aspirin use among outpatients with coronary artery disease. Although there is strong evidence that the use of aspirin reduces the risk of death and recurrent events in patients with coronary artery disease, current national patterns of aspirin use are unknown.

METHODS AND RESULTS

We used data from the 1980 to 1996 National Ambulatory Medical Care Surveys. These surveys provide a nationally representative sample of physician activities during patient visits to physician offices. We evaluated the report of aspirin as a new or continuing medication in 10 942 visits to cardiologists and primary care physicians by patients with coronary artery disease. We evaluated trends in the use of aspirin for 1980 to 1996 and used logistic regression to identify independent predictors of aspirin use for 1993 to 1996. Aspirin use in outpatient visits by persons with coronary artery disease without reported contraindications increased from 5.0% in 1980 to 26.2% in 1996. Large increases occurred in the early 1990s. Independent predictors of aspirin use in 1993 to 1996 were male patient gender (29% versus 21% for females), patient age of <80 years (28% versus 17% for age of >/=80 years), and presence of hyperlipidemia (45% versus 24% for patients without hyperlipidemia; all comparisons P<0. 001). Cardiologists (37%) were more likely to report aspirin use than were internists (20%), family physicians (18%), or general practitioners (11%; P<0.001). These effects persisted after we controlled for potential confounders with the use of logistic regression.

CONCLUSIONS

Although aspirin use in patients with coronary artery disease has increased dramatically, it remains suboptimum. Low rates of aspirin use and variations in use suggest a need to better translate clinical recommendations into practice.

Cholesterol management: an opportunity for nurse case managers

There is compelling scientific evidence that the modification of cardiovascular risk factors, including hypercholesterolemia, can reduce the incidence of myocardial infarction, effectively extend survival, decrease the need for interventional procedures, and improve quality of life in persons with and without known cardiovascular disease. Unfortunately, neither the publication of results from clinical trials of cholesterol lowering alone nor the 1993 National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPII) updated guidelines for the treatment of hypercholesterolemia have resulted in widespread changes in cholesterol management and control. Systematic nurse case management of dyslipidemias in patients with or at high risk for the development of coronary heart disease has the potential to improve compliance with NCEP-ATPII guidelines. In cooperation with physicians, nurses have the opportunity to address a major public health problem with the potential to eventually affect the more than 11 million people with coronary heart disease.

Undertreatment of hyperlipidemia in the secondary prevention of coronary artery disease

OBJECTIVES

To determine adherence to national guidelines for the secondary prevention of coronary artery disease (CAD) using lipid-lowering drugs (LLDs), by studying the rate of use of LLDs, predictors of use, and the rate of achieving lipid goals, among eligible patients recently hospitalized with acute myocardial infarction.

DESIGN

Cross-sectional analysis of 2,938 medical records, collected from July 1995 to May 1996.

SETTING

Thirty-seven community-based hospitals in Minnesota.

PATIENTS

The 622 patients had previously established CAD and hyperlipidemia (total cholesterol> 200 mg/dL or currently using LLDs), and were eligible for LLDs according to the National Cholesterol Education Program II (NCEP II) Guidelines.

MEASUREMENTS

The use of LLDs in eligible patients (primary outcome) and successful achievement of NCEP II goals (total cholesterol <160 mg/dL) among treated patients (secondary outcome).

MAIN RESULTS

Only 230 (37%) of 622 eligible patients received LLDs. In multivariate logistic regression, factors independently related to LLD use included age greater than 74 years (adjusted odds ratio [AOR] 0.55; 95% confidence interval [CI] 0.35, 0.88) and severe comorbidity (AOR 0.60; 95% CI 0.38, 0.95), managed care enrollee (AOR 1.56; 95% CI 1.02, 2.39), past smoker (AOR 1.72; 95% CI 0.98, 3.01), prior revascularization (AOR 2.31; 95% CI 1.51, 3.53), and the use of aspirin (AOR 1.59; 95% CI 1.07, 2.38) or >/=4 medications (AOR 2.89; 95% CI 2.19, 3.84). Of the treated patients who had lipid levels measured (n = 149), 15% achieved the recommended goal of a total cholesterol below 160 mg/dL. Of the untreated patients (n = 392), 89% were discharged from hospital without a LLD prescription.

CONCLUSIONS

Lipid-lowering drugs, although proven effective for the secondary prevention of CAD, were used by only one third of eligible patients. Among patients receiving LLDs, few achieved recommended lipid goals. Directed quality improvement interventions, such as starting LLDs during hospitalization, may have the potential to substantially reduce CAD morbidity and mortality in this vulnerable population.

Health care providers' perspectives on patient delay for seeking care for symptoms of acute myocardial infarction

To inform intervention development in a multisite randomized community trial, the Rapid Early Action for Coronary Treatment (REACT) project formative research was undertaken for the purpose of investigating the knowledge, beliefs, perceptions, and usual practice of health care professionals. A total of 24 key informant interviews of cardiologists and emergency physicians and 15 focus groups (91 participants) were conducted in five major geographic regions: Northeast, Northwest, Southeast, Southwest, and Midwest. Transcript analyses revealed that clinicians are somewhat unaware of the empirical evidence related to the problem of patient delay, are concerned about the practice constraints they face, and would benefit from concrete suggestions about how to improve patient education and encourage fast action. Findings provide guidance for selection of educational strategies and messages for health providers as well as patients and the public.

Frequency of lipid-lowering therapy after a coronary event in Helsinki, Finland

The results from a survey in Finland suggest an important treatment gap of lipid-lowering medications. Patients whose coronary artery disease was diagnosed before 1995 were less likely to be on lipid therapy than patients with a more recent diagnosis.

Low-density lipoproteins and risk for coronary artery disease

Based on the established relation between low-density lipoprotein (LDL) cholesterol and coronary artery disease (CAD), the treatment guidelines of the US National Cholesterol Education Program (NCEP) focus on LDL cholesterol reduction for primary and secondary prevention of CAD events. Abundant clinical trial evidence supports the importance of LDL cholesterol-lowering in decreasing CAD risk, both in angiographic trials, which measure CAD progression, and in trials with morbidity and mortality endpoints. The LDL cholesterol targets in the guidelines remain important treatment goals, and ongoing trials should answer questions of whether further reduction in LDL cholesterol will provide much additional benefit. Even in trials of statin therapy, in which substantial reductions of LDL cholesterol have been obtained, statins decrease (by 23-37%) but do not entirely eliminate events, suggesting that lipid parameters besides LDL cholesterol, such as high-density lipoprotein (HDL) cholesterol, triglyceride, lipoprotein(a), and LDL particle size and susceptibility to oxidation, as well as other risk factors, influence CAD risk. Unfortunately, at present, the majority of high-risk patients are not receiving either diet or drug therapy. Systematic screening to identify high-risk patients and methodical follow-up to implement diet, lifestyle modification, and drug therapy to lower LDL cholesterol, as provided for in the NCEP guidelines, should lead to significant benefits in the prevention of CAD events.

Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels

BACKGROUND

In patients with coronary heart disease and a broad range of cholesterol levels, cholesterol-lowering therapy reduces the risk of coronary events, but the effects on mortality from coronary heart disease and overall mortality have remained uncertain.

METHODS

In a double-blind, randomized trial, we compared the effects of pravastatin (40 mg daily) with those of a placebo over a mean follow-up period of 6.1 years in 9014 patients who were 31 to 75 years of age. The patients had a history of myocardial infarction or hospitalization for unstable angina and initial plasma total cholesterol levels of 155 to 271 mg per deciliter. Both groups received advice on following a cholesterol-lowering diet. The primary study outcome was mortality from coronary heart disease.

RESULTS

Death from coronary heart disease occurred in 8.3 percent of the patients in the placebo group and 6.4 percent of those in the pravastatin group, a relative reduction in risk of 24 percent (95 percent confidence interval, 12 to 35 percent; P<0.001). Overall mortality was 14.1 percent in the placebo group and 11.0 percent in the pravastatin group (relative reduction in risk, 22 percent; 95 percent confidence interval, 13 to 31 percent; P<0.001). The incidence of all cardiovascular outcomes was consistently lower among patients assigned to receive pravastatin; these outcomes included myocardial infarction (reduction in risk, 29 percent; P<0.001), death from coronary heart disease or nonfatal myocardial infarction (a 24 percent reduction in risk, P<0.001), stroke (a 19 percent reduction in risk, P=0.048), and coronary revascularization (a 20 percent reduction in risk, P<0.001). The effects of treatment were similar for all predefined subgroups. There were no clinically significant adverse effects of treatment with pravastatin.

CONCLUSIONS

Pravastatin therapy reduced mortality from coronary heart disease and overall mortality, as compared with the rates in the placebo group, as well as the incidence of all prespecified cardiovascular events in patients with a history of myocardial infarction or unstable angina who had a broad range of initial cholesterol levels.

Gender differences in barriers to lifestyle change for cardiovascular disease prevention

Achieving and maintaining a healthy lifestyle are important aspects of a cardiovascular disease prevention program. Few data have evaluated barriers to lifestyle change by gender. We studied self-reported barriers to lifestyle change and evaluated support systems to make positive changes in 293 patients (186 men, 107 women) enrolled in a multidisciplinary preventive cardiology clinic. Subjects were asked to rate barriers and support systems on a scale of 1 to 5, with 1 being very important and 5 not important. Women ranked self-esteem as the most important barrier and rated it significantly higher than did men (p = 0.0003). Women also rated money, knowledge, skills, and stress significantly higher than did men (p < 0.05). Physicians were rated as the most important source of support for both genders. Women, compared with men, rated dietitians, exercise physiologists, nurses, counselors, family members, and social/religious groups as more important sources of support. These data suggest that gender differences exist in barriers to lifestyle change. Psychosocial factors should be considered important elements of programs designed to help patients make positive lifestyle changes.

A perspective on hyperlipidemia: concepts of management in the prevention of coronary artery disease

The clinical benefits of lowering elevated serum cholesterol for both primary and secondary prevention of coronary artery disease are now well established. Reduction in clinical events occurs early and appears to be related to stabilization of atherosclerotic plaque. Despite these salutary findings, lipid-lowering therapy, both nondrug and pharmacologic, is still markedly underutilized in patients and high-risk individuals in the asymptomatic population. Recent practical and uncomplicated guidelines present a rational strategy for selection of patients for low-density lipoprotein (LDL) cholesterol reduction and have the potential to yield major clinical benefits if properly implemented. Preventive cardiology measures should be applied by matching the intensity of the intervention to the hazard for clinical events. We support the current guidelines of the expert panels described in this article and propose several extensions for cholesterol lowering in selected, high-risk populations.

Behavioral issues in the efficacy versus effectiveness of pharmacologic agents in the prevention of cardiovascular disease

A number of pharmacologic interventions are now recommended for the prevention of cardiovascular disease, based on the results of randomized controlled trials. These include antihypertensive drugs, lipid-lowering agents, antiplatelet and anticoagulant drugs, estrogen replacement therapy, beta-blockers, and angiotensin converting enzyme (ACE) inhibitors. It is likely that additional pharmacologic interactions will soon be proven efficacious. Despite the strength of this evidence and the development of clinical guidelines incorporating their use, a surprisingly low proportion of patients are actively treated with these agents. There may be a variety of explanations for this, including barriers at the level of the patient, health care provider, and health care institution. Finally, a number of questions remain as to the optimal combination of interventions, both behavioral and pharmacologic, which will yield maximal reduction in risk. The description of factors which reduce the effectiveness of pharmacologic interventions below the efficacy demonstrated in randomized clinical trials should be a fertile area for epidemiologic and behavioral research.

Lipid lowering in a multidisciplinary clinic compared with primary physician management

A multidisciplinary lipid reduction clinic achieved greater reduction of serum cholesterol when compared with primary physicians among patients with coronary heart disease. The lipid clinic was more likely than the primary physicians to prescribe lipid-lowering medication, to prescribe multiple medications, and to use drug doses in excess of the "starting dose."

A new model for risk stratification and delivery of cardiovascular rehabilitation services in the long-term clinical management of patients with coronary artery disease

This model for risk stratification includes variables that classify patients for Risk of Event similar to current models of risk stratification, as well as variables that stratify patients for Risk of Progression of Atherosclerosis by established risk factors. Categories of risk are established using accepted data from the literature for each risk factor that targets regression or plaque stabilization as the goal for Low Risk. A case-rate charging system and the proposed removal of time restrictions for length of cardiovascular rehabilitation fit neatly into the present climate for health care. Health maintenance organizations will be seeking programs that use similar models to address cost issues inherent in cardiovascular rehabilitation programs under current fee-for-service models. Improved outcomes will also be targets for these programs and case-management lends itself to disease management, thus, improved outcomes. Tracking outcomes becomes even more important to both the provider and the insurer because results drive referrals. Likewise, removal of the time restriction for cardiovascular rehabilitation allows programs to individualize care and to target risk factors that are not only most deleterious, but also where patients show readiness for change. The changing environment of health care virtually mandates change in cardiovascular rehabilitation. It is imperative that programs manage the disease process, are effective in achieving outcomes that affect both patient function and the disease process, and are cost effective. This model for risk stratification and delivery of services addresses these requirements and provides a beginning for implementing these changes in cardiovascular rehabilitation.

Management of hypercholesterolemia: practice patterns for primary care providers and cardiologists

This retrospective study, conducted as part of a private practice quality assurance process for patients with coronary artery disease (CAD), compares practice patterns in the LIFEHELP lipid clinic and non-lipid clinic settings at the Heart Institute of St. Petersburg. Quality assurance parameters included documentation of low-density lipoprotein (LDL) cholesterol, initiation of lipid-lowering therapy, and achievement of the Second National Cholesterol Education Program (NCEP II) goal for CAD patients of LDL cholesterol < or =100 mg/dL. A total of 934 patient charts with ICD-9 codes of 410-414 for ischemic heart disease were randomly selected and reviewed by a utilization review nurse. A higher level of documentation and treatment of elevated LDL cholesterol to NCEP II goal in CAD patients was found for those followed in the lipid clinic. Among non-lipid clinic physicians, cardiologists documented and treated elevated LDL cholesterol more frequently than primary care physicians. Women and the elderly subgroups received improved care in the lipid clinic setting. Screening activities and risk-factor management by cardiologists within a lipid clinic, therefore, demonstrated an improved standard of care that came closer to achieving national guidelines in the secondary prevention of CAD.

Comprehensive cardiovascular disease risk reduction in a cardiac rehabilitation setting

Cardiac rehabilitation combines prescriptive exercise training with coronary artery disease (CAD) risk factor modification in patients with established CAD. As such, cardiac rehabilitation programs are ideally positioned to assume a pivotal role in the rendering of many components of comprehensive cardiovascular disease risk reduction in a secondary prevention setting. However, the extent to which traditional cardiac rehabilitation programs can successfully accomplish this goal is limited by low participation rates, inadequate emphasis on many of the essential aspects of secondary prevention, and lack of long-term follow-up of patients. To overcome these deficiencies, cardiac rehabilitation programs should evolve into cardiovascular risk reduction programs by implementing approaches that have been shown to be effective in randomized clinical trials. In this manuscript we describe one such approach, based on the Stanford Coronary Risk Intervention Project, which has been implemented in > 1,000 patients. Key components of this physician-supervised, nurse case-manager model include: (1) initial evaluation and risk assessment; (2) identification of specific goals for each CAD risk factor; (3) formulation and implementation of an individualized treatment plan that includes lifestyle modification and pharmacologic interventions for accomplishing specific risk reduction goals; (4) long-term follow-up to enhance compliance and revise the treatment plan as indicated; and (5) a mechanism for outcomes based long-term assessment of each patient.

Effects of fluvastatin on coronary atherosclerosis in patients with mild to moderate cholesterol elevations (Lipoprotein and Coronary Atherosclerosis Study [LCAS])

Despite the potential for reduced morbidity and mortality, aggressive intervention against mild to moderate hypercholesterolemia in patients with coronary heart disease (CHD) remains controversial and infrequently practiced. Eligible patients in the 2.5-year Lipoprotein and Coronary Atherosclerosis Study were men and women aged 35 to 75 years with angiographic CHD and mean low-density lipoprotein (LDL) cholesterol of 115 to 190 mg/dl despite diet. Patients (n = 429; 19% women) were randomized to fluvastatin 20 mg twice daily or placebo. One fourth of patients were also assigned open-label adjunctive cholestyramine up to 12 g/day because prerandomization LDL cholesterol remained > or = 160 mg/dl. The primary end point, assessed by quantitative coronary angiography, was within-patient per-lesion change in minimum lumen diameter (MLD) of qualifying lesions. Across 2.5 years, mean LDL cholesterol was reduced by 23.9% in all fluvastatin patients (+/- cholestyramine) (146 to 111 mg/dl) and by 22.5% in the fluvastatin only subgroup (137 to 106 mg/dl). Primary end point analysis (340 patients) showed significantly less lesion progression in all fluvastatin versus all placebo patients, deltaMLD -0.028 versus -0.100 mm (p <0.01), and for fluvastatin alone versus placebo alone, deltaMLD -0.024 versus -0.094 mm (p <0.02). A consistent angiographic benefit with treatment was seen whether baseline LDL cholesterol was above or below 160 or 130 mg/dl. Beneficial trends with treatment were also consistently seen in clinical event rates but were not statistically significant. Thus, lipid lowering by fluvastatin in patients with mildly to moderately elevated LDL cholesterol significantly slowed CHD progression.

Atherosclerotic risk factors are less intensively treated in patients with peripheral arterial disease than in patients with coronary artery disease

OBJECTIVE

To compare rates of therapy for atherosclerotic risk factors between patients with lower extremity peripheral arterial disease (PAD) and patients with coronary artery disease (CAD).

DESIGN

Cross-sectional.

SETTING

Academic medical center.

PATIENTS/PARTICIPANTS

Three hundred forty-nine consecutive patients diagnosed with PAD or CAD identified from the blood flow and cardiac catheterization laboratories, respectively.

MEASUREMENTS AND MAIN RESULTS

Participants were interviewed by telephone for medical history as well as therapies prescribed and recommended by their physicians. Among patients with hypercholesterolemia, more CAD patients were taking cholesterol-lowering drugs (58% vs 46%, p = .08) and more CAD patients recalled a physician's instruction to follow a low-fat, low-cholesterol diet (94% vs 83%, p = .01). CAD patients were more likely to exercise regularly (71% vs 50%, p < .01). Among patients not exercising, more CAD patients recalled a physician's advice to exercise (74% vs 47%, p < .01). In logistic regression analysis, hypercholesterolemic patients with exclusive CAD were more likely to be treated with drug therapy (odds ratio [OR] 2.3, p = .05). CAD patients were more likely to recall advice to exercise (OR 4.0, p < .001), and more likely to be taking aspirin or warfarin (OR 4.8, p = .01).

CONCLUSIONS

Atherosclerotic risk factors are less intensively treated among PAD patients than CAD patients. A number of possible explanations could account for these disparities in therapeutic intensity.

The multilevel compliance challenge: recommendations for a call to action. A statement for healthcare professionals

Despite the universally accepted importance of compliance, strategies known for more than two decades to be effective are not routinely incorporated into clinical practice. For the benefits of primary and secondary prevention to be realized in diverse population groups and settings, emphasis must be placed on implementing strategies at the patient, provider, and organization levels. Current knowledge of compliance strategies, if integrated into a multilevel approach, offers enormous promise for decreasing risk and improving patient outcomes.

[The future of cardiology in Spain from the perspective of the last 30 years]

Socioeconomic and geoenvironmental factors combined with technological advances play a decisive role in diseases control and in the imbalances in health care among countries and also among social groups within one country. We discuss the frequency and trends of cardiovascular disease in Spain during the last 30 years, the socioeconomical changes in health care and the role of the cardiologist over the last decade, as a background for the challenges to be addressed as the year 2000 approaches: the role of the demographic changes in the frequency of cardiac diseases, the control of "new" postsurgical populations, the integration of basic research in departments of cardiology, the selection of new technologies in terms of cost-effectiveness by means of randomized trials and the need to bridge the gap between the overflow of protocols, recommendations and consensus and their application to the population.

Cost effectiveness of risk reduction: the managed care perspective

Coronary artery disease (CAD) is responsible for nearly $140 billion in healthcare expenditures each year. A major opportunity for cost savings lies in reducing the overutilization of hospitalization for CAD patients. This goal may be accomplished through several strategies: more precise diagnosis of CAD, primary and secondary prevention, and early intervention. Underutilization of health services and treatment also contributes to higher overall medical costs. Even though drug therapy incurs costs, effective medications can produce substantial savings by reducing the need for additional medical care. For example, lipid-lowering agents are particularly cost effective when used as secondary prevention in patients with CAD; however, only 25% of patients receive such therapy. Likewise, not all patients who suffer acute myocardial infarction are treated with any of the agents proven to reduce the risk of subsequent adverse cardiovascular events. The elimination of variability in prescribing practices should help optimize the cost effectiveness of therapies aimed at reducing CAD risk.