Thedentons.us

EDITORIAL
Secondary Prevention After Coronary Bypass: The
American Heart Association “Get With the
Guidelines” Program
Timothy A. Denton, MD, Gregg C. Fonarow, MD, Kenneth A. LaBresh, MD, and
Alfredo Trento, MD
Divisions of Cardiology and Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, Division of Cardiology,
University of California Los Angeles School of Medicine, Los Angeles, California, and Mass Pro, Providence, Rhode Island
Invasive coronary procedures such as coronary artery blood pressure in diabetic patients, 130/80 mm Hg, (4)
bypass grafting (CABG) and percutaneous translumi-
recommending a more conservative body mass index
nal coronary angioplasty (PTCA) have changed the face
(lower limit 18.5 kg/m2), and (5) removing estrogen
of cardiac care, providing significant improvements in
recommendations.
survival and quality of life for patients with coronary
Further, the guidelines now strongly support the con-
artery disease (CAD). In 1999 there were almost 1 million
cept that these medical therapies should be started in the
invasive procedures performed in the United States
hospital during a patient’s acute coronary event or vas-
and their clinical benefit has been demonstrated in a
cular procedure. These recommendations are based on
multitude of investigations. The importance of these
compelling data indicating that in-hospital initiation of
procedures is clear but they do not exist in isolation—
medical therapy can improve patient compliance and
their foundation lies in the medical therapy that should
outcomes
be optimized in all patients with CAD.
Although the importance of optimal medical therapy is
self-evident, a large body of literature demonstrates its
Adherence to Published Guidelines
underutilization in patients with vascular disease
The publication of a guideline does not mean that rec-
This treatment gap indicates we are not providing med-
ommendations will automatically be translated into daily
ical therapy for patients who need it most. In this review
we discuss medical therapies known to alter the athero-
practice, a fact clearly demonstrated with the implemen-
sclerotic process based on the secondary prevention
tation of the atherosclerotic secondary prevention guide-
guidelines of the American Heart Association (AHA) and
lines demonstrates that adherence to the
the American College of Cardiology (ACC). We also
AHA/ACC guidelines varies between 10% and 90%.
introduce a nationwide program from the AHA called
Many reasons are described for this lack of adherence to
“Get with the Guidelines,” the goal of which is to assure
guidelines Lack of knowledge, information over-
that all patients with known vascular disease are dis-
load, poor documentation, and forgetfulness, among
charged from the hospital with the secondary prevention
many others, have all been enumerated as causes for
guidelines addressed.
poor adherence. To cite an example, although 95% of a
group of physicians were aware of specific guidelines for
cholesterol lowering, only 18% of the same physicians’
Secondary Prevention Guidelines
patients were at NCEP recommended low-density li-
The AHA and ACC have published detailed secondary
poportein cholesterol goals
prevention guidelines for medical therapy in patients
The fact remains that implementation of the secondary
with vascular disease that include specific drug
prevention guidelines can have a huge impact on the
recommendations (antithrombotics, beta blockers, angio-
outcome of our patients with vascular disease and we are
tension-converting enzyme [ACE] inhibitors, and lipid
thus obliged to specifically address known deficiencies in
agents), disease management (diabetes, hypertension),
medical therapy. The question remains, how— exactly—
and lifestyle changes (exercise, smoking cessation,
can we do this?
weight management). The most recent guideline itera-
tion addresses new data and recommendations from
other national organizations Changes from previous
AHA “Get With the Guidelines” Program
guidelines include (1) considering ACE inhibitors for all
Because of the demonstrated treatment gap in patients
patients with atherosclerotic disease, (2) considering di-
with vascular disease and the evidence that hospital-
abetic patients as “vascular disease equivalents” for the
purposes of lipid therapy, (3) establishing a new goal for
based systems can markedly improve treatment rates
and outcomes, the AHA initiated a program entitled “Get
with the Guidelines” (GWTG). The goal of GWTG is to
Address reprint requests to Dr Denton, Heart Institute of the High Desert,
12332 Hesperia Rd, Victorville, CA 92332; e-mail: [email protected].
assure that all patients with vascular disease in an acute
2003 by The Society of Thoracic Surgeons
Ann Thorac Surg 2003;75:758 – 60 • 0003-4975/03/$30.00
Published by Elsevier Science Inc
PII S0003-4975(02)04885-3
Ann Thorac Surg
EDITORIAL
DENTON ET AL
2003;75:758 – 60
GET WITH THE GUIDELINES PROGRAM
Table 1. AHA/ACC Guidelines for Secondary Prevention
Compliance
Risk/Therapy
Long-Term Goal
GWTG Goal
Antithrombotics
Aspirin 75 to 325 mg/day
Drug therapy initiated
56%– 84%
Warfarin INR 2.0 –3.0
Beta blockers
Indefinitely for post-MI and ischemic syndrome patients
Drug therapy initiated
17%–73%
ACE inhibitors
Indefinitely for post-MI and CHF; consider for all vascular
Drug therapy initiated
patients
Low-density lipoprotein Ͻ 100
Drug therapy initiated
Diabetes
Hemoglobin A1c Ͻ 7%
Drug therapy initiated
Hypertension
Blood pressure (mm Hg)
Ͻ 140/90 on discharge
Ͻ140/90 for most patients
Ͻ130/85 for CHF or renal failure
Ͻ130/80 for diabetes
Complete cessation
Counseling
Physical activity
30 min, 3– 4 times per week
Counseling
19%– 42%
Weight management
18.5 Յ BMI Յ 24.9
Counseling
The first column is the risk factor or therapy to be addressed, the second column is the specific recommended goal, and the third column is the Get With
the Guidelines (GWTG) goal prior to hospital discharge. Column four is the rate of compliance from various studies in the medical literature.
ACE ϭ angiotensin-converting enzyme;
AHA/ACC ϭ American Heart Association/American College of Cardiology;
BMI ϭ body mass
CHF ϭ congestive heart failure;
INR ϭ international normalized ratio;
MI ϭ myocardial infarction.
care hospital are discharged with the nine guidelines
Implementation in Cardiac Surgery
addressed and well-documented.
Cardiovascular surgical programs are ideal locations for
It is important to emphasize that GWTG at present
GWTG. Post-CABG patients (or any vascular surgery
focuses on assuring that patients being discharged from
patient) are in a controlled environment in which patient
the hospital have the guidelines addressed. That is, the
and family education is easier and both patient and
goals of GWTG are (1) initiating drug therapy, (2) coun-
family are motivated to make changes in their lives given
seling regarding lifestyle changes, and (3) achieving a
the procedure that they have just undergone. Most post-
blood pressure of less than 140/90 mm Hg—all before
CABG patients also have a “standard” postoperative
discharge. The third column of gives the specific
course that is easily modifiable by a series of clinician
goals of the GWTG program with respect to each of the
reminders, standard orders, and other systems that as-
nine measures. In the future GWTG may become more
sure all patients with vascular disease are discharged
involved in outpatient care and achieving all of the
with the nine guidelines addressed.
specific secondary prevention goals but for now the
To cite a specific example the Division of Cardiotho-
primary focus is the time of hospital discharge.
racic Surgery at Cedars-Sinai Medical Center has been
In May 2000 a pilot program of GWTG was initiated
successful in achieving significant improvements in med-
with the New England Affiliate of the AHA. In Massa-
ical therapy after CABG. Through educational programs
chusetts 24 multidisciplinary teams participated in a
(physicians, physician assistants, nurses, residents, and
conference that was divided into a didactic session con-
cardiology fellows), reminders, changes in standard or-
sisting of a review of guidelines and potential implemen-
ders, and a computerized discharge system they have
tation methods and a goal-oriented interactive session in
been able to increase their appropriate treatment rate to
which small groups were organized to allow the partici-
exceed 90% Clearly some of the deficiencies were
pants to develop implementation plans for their particu-
poor documentation but GWTG addresses these issues.
lar settings. Since then the New England group has held
We believe that this type of progress is possible in all
two additional meetings and the number of participating
cardiovascular surgery programs of all sizes.
hospitals has grown to 52.
Many hospitals have demonstrated significant im-
provements in guideline implementation in a variety of
The Future
areas of cardiovascular care. As an example one rural
Implementation of optimal medical care in vascular dis-
Massachusetts teaching hospital attained a 100% success
ease patients can provide significant survival and quality
rate in applying all of the nine guidelines to its patients
of life benefits, and through GWTG the AHA is attempt-
with coronary artery disease. Because of the success of
ing to mobilize medical communities throughout the
the New England pilot program the AHA national orga-
country to join the effort. A variety of national, regional,
nization approved GWTG to be rolled out across the
and local organizations have joined the GWTG program
United States and is now being initiated in all regions of
to achieve these goals. Lipid organizations, governmental
the country.
public health divisions, state medical organizations, and
EDITORIAL
DENTON ET AL
Ann Thorac Surg
GET WITH THE GUIDELINES PROGRAM
2003;75:758 – 60
that a new technology can provide significant benefit.
The cardiovascular surgical community would be a major
addition to the GWTG effort locally, regionally, nation-
ally, and on the individual patient level. Please join us.
References
1. Popvic JR. 1999 National hospital discharge survey: annual
summary with detailed diagnosis and procedure data. Vital
Health Stat 2001;13.
2. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treat-
ment assessment project (L-TAP): a multicenter survey to
evaluate the percentages of dyslipidemic patients receiving
lipid-lowering therapy and achieving low-density lipopro-
tein cholesterol goals. Arch Intern Med 2000;160:459 –67.
Fig 1. Proportion of patients discharged on the nine guidelines after
3. Pearson TA, Peters TD. The treatment gap in coronary artery
coronary artery bypass graft surgery, before (black bar, n ϭ 93)
disease and heart failure: community standards and the
and after (white bar, n ϭ 67) the “Get With the Guidelines” pro-
post-discharge patient. Am J Cardiol 1997;80:45H–52H.
gram was implemented in the Cedars-Sinai Medical Center Division
4. Abookire SA, Karson AS, Fiskio J, et al. Use and monitoring
of Cardiothoracic Surgery. (ACE ϭ angiotensin-inhibiting enzyme
of “statin” lipid-lowering drugs compared with guidelines.
inhibitor; ASA ϭ aspirin; Beta ϭ beta blocker; BMI ϭ body mass
Arch Intern Med 2001;161:53–8.
index; Chol ϭ cholesterol-lowering agent; DM ϭ diabetes mellitus;
5. Muhlestein JB, Horne BD, Bair TL, et al. Usefulness of
Exerc ϭ exercise; HTN ϭ hypertension; Smoke ϭ smoking
in-hospital prescription of statin agents after angiographic
cessation.)
diagnosis of coronary artery disease in improving compli-
ance and reduced mortality. Am J Cardiol 2001;87:256 –61.
6. Smith SC, Blair SN, Bonow RO, et al. AHA/ACC guidelines
many others are participating in the GWTG program. We
for preventing heart attack and death in patients with
believe that the cardiovascular surgery community in
atherosclerotic cardiovascular disease: 2001 update. Circula-
general and the Society of Thoracic Surgeons (STS) in
tion 2001;104:1577–9.
7. Grundy SM, Balady GJ, Criqui MH, et al. When to start
particular would be a formidable addition to GWTG.
cholesterol-lowering therapy in patients with coronary heart
Participation might occur at various levels. First, the
disease. A statement for healthcare professionals from the
STS might encourage all members to participate directly
American Heart Association task force on risk reduction.
in the regional and national GWTG efforts. That would
Circulation 1997;95:1683–5.
include STS participation in the national and regional
8. Fonarow GC, Gawlinski A, Moughrabi S, Tillisch JH. Im-
meetings in addition to serving as local experts on
proved treatment of coronary heart disease by implementa-
tion of a cardiac hospitalization atherosclerosis management
optimizing medical care. Second, the STS as an organi-
program (CHAMP). Am J Cardiol 2001;87:819 –22.
zation might consider modifying the national database to
9. Roberts CS. Postoperative drug therapy to extend survival
include the nine guidelines as measures of in-hospital
after coronary artery bypass grafting. Ann Thoracic Surg
quality of care—to be tracked and reported, just like
2000;69:1315–6.
mortality and morbidity. Furthermore all cardiovascular
10. Schwartz GG, Olsson AG, Ezekowitz MD, et al, the Myocar-
dial Ischemia Reduction with Aggressive Cholesterol Low-
surgeons—irrespective of their direct involvement in the
ering (MIRACL) Study Investigators. Effects of atorvastatin
GWTG program— could provide even more patient ben-
on early recurrent ischemic events in acute coronary syn-
efit by assuring that when a patient leaves their care, the
dromes. The MIRACL study: a randomized controlled trial.
patient has received every beneficial therapy, both sur-
JAMA 2001;285:1711–8.
gical and medical.
11. Larme AC, Pugh JA. Attitudes of primary care providers
toward diabetes: barriers to guideline implementation. Dia-
Historically cardiovascular surgeons have always been
betes Care 1998;21:1391–6.
at the forefront of care—in developing new technology,
12. Smith WR. Evidence for the effectiveness of techniques to
in moving that technology to the bedside, and in proving
change physician behavior. Chest 2000;118:8S–17S.

Source: http://www.thedentons.us/Medical/AnnThoracSurgGWTG.pdf