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

The Swedish National Programme for Quality Control of Secondary Prevention of Coronary Artery Disease - results after one year

BACKGROUND

Guidelines for the prevention of coronary artery disease (CAD) have been developed both in Europe and in the USA. However, several surveys have shown that these guidelines are poorly implemented in clinical practice.

DESIGN/METHODS

The Swedish Quality Control Programme on Secondary Prevention of CAD includes patients after myocardial infarction, or having undergone coronary artery surgery or percutaneous coronary intervention. Fifty of Sweden's 79 hospital districts are currently participating. Patients are asked to send report-cards regarding risk factor management to a central registry after discharge from hospital, at a 3-6 month visit and then yearly for 5 years.

RESULTS

Results based on data from 1 year after the index event show that a majority of patients reach targets for serum cholesterol (70%), and low-density lipoprotein (LDL)-cholesterol (71%). Mean value for total cholesterol is 4.6 (+/-SD 0.9) mmol/l, LDL-cholesterol 2.7 (+/-SD 0.8) mmol/l. Blood pressure targets are less often achieved, with 58% reaching the European Society of Cardiology target for systolic (<140 mmHg) and 81% for diastolic (<90 mmHg) blood pressure. A large proportion of patients are prescribed preventive drugs: aspirin (96%), beta-blockers (78%) and lipid-lowering drugs (83%).

CONCLUSIONS

The Swedish Quality Control Programme is one of the first attempts to assess implementation of guidelines on a national level based on patient participation. It is hoped that shared care programmes and increased patient involvement with feedback on achieved treatment goals in relation to guidelines will improve outcomes in patients with CAD.

Physician Perceptions of Enhanced Community Pharmacist Care in Cholesterol Management

Objectives:

The Study of Cardiovascular Risk Intervention by Pharmacists (SCRIP) was a randomized controlled trial that demonstrated that community pharmacist intervention improved cholesterol management for patients at high risk for cardiovascular disease. The objective of this sub-study was to describe physician perceptions of the intervention program.

Design:

Surveys were mailed to all physicians contacted as part of the enhanced pharmacist care program within SCRIP. Physician opinions were collected on pharmacist participation in cholesterol management and the impact of the program on patient management and outcomes.

Results:

We received 141 usable surveys from 239 eligible physicians, a response rate of 59%. Of those who responded, 110 (78%) remembered components of the enhanced pharmacist care program, and 77 (55%) were in favour of the pharmacist's recommendations. Of the 110 physicians who recalled the intervention, 27 (25%) agreed that the program improved cholesterol management, and 11 (10%) felt the program had a major effect on patient outcomes; however, only 41 (37%) felt the program was helpful or useful. Written comments reflected opinions that the program duplicates current services and that physicians have reservations about the expanding role of pharmacists. Despite these general comments, similar interventions for other medical conditions were welcomed.

Conclusions:

Physicians had mixed attitudes toward the enhanced pharmacist care program. Despite these opinions, the main results of SCRIP were very positive. Indeed, if the physician opinions of the program had been more positive, the impact might have been even greater. The effectiveness of future programs may be enhanced through improved communication of the program's goals and collaboration of all stakeholders early in the program's implementation.

Appropriateness of cholesterol management in primary care by sex and level of cardiovascular risk

A study was undertaken to ascertain the appropriateness of lipid screening and management per the Third Report of the Adult Treatment Panel National Cholesterol Education Program (ATP III) guideline in a sample of North Carolina primary care practices. Demographics, cholesterol values, and comorbid conditions were abstracted from the medical records from 60 community practices participating in a randomized practice-based trial (Guideline Adherence for Heart Health). Eligible patients were aged 21 to 84 years, seen during the baseline period of June 1, 2001, through May 31, 2003, and who were not taking lipid-lowering therapy. Multivariable logistic regression was utilized to assess whether age, sex, race/ethnicity, diabetes, cardiovascular disease, ATP III risk category, or pretreatment low-density lipoprotein (LDL) influenced treatment. Among 5031 eligible patients, 1711 (34.5%) received screening lipid profiles. Screening rates were higher with older age, diabetes, and cardiovascular disease. No large differences were seen by sex. Among patients screened (mean age, 51.6 years; 57.9% female), 76.6% were appropriately managed within 4 months. In adjusted analyses, older age was associated with less appropriate treatment (odds ratio [OR] per 5 years, 0.91; P=.01), and patients with LDL cholesterol <or=130 mg/dL (OR, 18.8; P<.001) and the low-risk group (OR, 27.5; P<.001) were more likely to be managed appropriately compared with patients with LDL >or=190 mg/dL and those at high risk. Among 375 patients eligible for drug treatment, those with LDL levels between 131 and 159 mg/dL were much less likely to be treated (OR, 0.15; P<.001) compared with those with LDL >190 mg/dL, whereas risk category did not influence treatment. The challenge facing implementation of ATP III guidelines is much greater for intermediate- and high-risk patients than for low-risk patients.

Hyperlipidemia guideline adherence and association with patient gender

BACKGROUND

Gender disparities in cardiovascular disease (CVD) management have become increasingly apparent in recent years. Previous research has focused on inpatient disparities, but little is known about how patient gender affects assessment, treatment, and management of patients for hyperlipidemia and cardiovascular risk in primary care settings. Patients with coronary artery disease (CAD) and hyperlipidemia are at high risk for cardiovascular and cerebrovascular morbidity. We sought to examine the effect of patient gender on assessment, treatment, and target maintenance of hyperlipidemia among patients with CAD in a primary care setting.

METHODS

Chart abstraction was done for 715 patients with CAD in 55 family practices in New Jersey and eastern Pennsylvania as part of the Using Learning Teams for Reflective Adaptation (ULTRA) project. Hyperlipidemia assessment, treatment, and target adherence scores were determined for those at-risk patients based on National Heart, Lung, and Blood Institute (NHLBI) recommended National Cholesterol Education Program (NCEP) ATP III guidelines. Generalized linear models were used to determine the association of hyperlipidemia guideline adherence with patient gender, using comorbidities and age as confounders.

RESULTS

After controlling for comorbidities and age, women were less likely to be assessed for lipids (p = 0.0462). There was no difference in treatment (p = 0.1074) or target laboratory values (p = 0.3949).

CONCLUSIONS

Women with CAD are less often assessed for lipids than men in primary care practices. More intensive efforts may be necessary to educate physicians and patients about cardiovascular risk for women.

Quality of cholesterol screening and management with respect to the National Cholesterol Education's Third Adult Treatment Panel (ATPIII) guideline in primary care practices in North Carolina

BACKGROUND

Adherence to previous national cholesterol guidelines has been low. We assessed whether lipid screening and management was consistent with the National Cholesterol Education's ATPIII in a sample of primary care practices participating in a quality improvement study.

METHODS

Demographic and clinical data were abstracted from charts of 5071 patients aged 21 to 84 years, which were seen between June 1, 2001, and May 31, 2003, at 60 practices. Clinical sites were non-university-based primary care practices from 22 North Carolina counties. A dyslipidemia screening test was defined as a lipid profile performed on persons when not on a lipid-lowering drug. Among patients receiving a lipid profile, the proportion of patients appropriately treated, per ATPIII, was calculated. Practice level variation in screening and management was examined using the 50th (20th and 80th) percentile values across practices.

RESULTS

The median practice level dyslipidemia screening rate during the 2 years was 40.1% (25.8%, 53.7%) of their age-eligible patients. The appropriate decision regarding lipid-lowering therapy was documented within 4 months of the lipid profile for 79.3% (69.0%, 86.0%) of practices' patients. Within 4 months, among the drug-ineligible patients, 100% (94%, 100%) were not prescribed drugs; 33.3% (6.3%, 50.0%) of the drug-eligible patients were prescribed lipid-lowering agents.

CONCLUSIONS

The median dyslipidemia screening rate met the recommendations. There remains a need to improve the management of dyslipidemia; in particular, there was a significant underprescription of lipid-lowering drugs.

Surveillance and treatment of dyslipidemia in the post-infarct patient: can a nurse-led management approach make a difference?

BACKGROUND

Lowering plasma lipid levels in patients in the months following hospital discharge for a myocardial infarction (MI) is clearly beneficial if recurrent cardiac events and mortality are to be prevented; traditionally, however, there has been a large gap between guidelines and levels achieved in routine practice.

OBJECTIVES AND METHODS

A randomized, open-label clinical trial was conducted to assess the impact of nurse-centred surveillance and treatment in achieving nationally recognized lipid targets in post-MI patients. This program had the following features: systematic telephone follow-up of patients discharged from the University of Sherbrooke (Sherbrooke, Quebec) after an MI; systematic lipid testing three months after discharge; close liaison with, and guidance of, patients' primary care physicians to intervene on results of this test if targets were not obtained; and continued monitoring of patients until lipid profiles consistent with consensus targets were achieved. The impact of this approach was tested and compared with that of a control group that continued to be followed by a primary care physician for up to 18 months.

RESULTS

A total of 127 patients were randomly assigned into an intervention group (n=64) or a control group (n=63). The intervention group was followed by telephone for an average (+/-SD) of 4.4+/-2.0 months post-MI. At this point, when intervention was optimized, the mean low-density lipoprotein cholesterol (LDL-C) level was 2.19+/-0.65 mmol/L in the intervention group, and 87.3% of patients had LDL-C levels of less than 2.5 mmol/L. Patients from both experimental groups returned at 12 months and 18 months post-MI for a new blood lipid assessment. In total, 12.5% of patients in each group were lost to follow-up. At 12 months and 18 months, the mean LDL-C level was not different between the two groups, nor was there a significant difference in the proportion of patients achieving LDL-C levels of less than 2.5 mmol/L (51.6% in the intervention group and 65% in the control group at 18 months; P>0.05). When the combined end point of an LDL-C level of less than 2.5 mmol/L, a triglyceride level of less than 2.0 mmol/L and a total cholesterol to high-density lipoprotein cholesterol ratio of less than 4.0 was considered, the proportion of patients achieving this composite at 18 months was low and not different between the two groups (23.4% in the intervention group and 38.3% in the control group; P>0.05). Over 95% of patients in both groups were on a lipid-lowering medication, and more than 90% had complied with their medication regimen at 18 months.

CONCLUSIONS

This trial did not support the role of nurse-managers and a system of telephone-based contacts to ensure the continuity of care and aggressive intervention when considering cardiovascular risk factors in post-MI patients. This trial also re-emphasized the important remaining treatment gap in secondary prevention of coronary artery disease, particularly if composite lipid end points are to be targeted.

The impact of physician attitudes and beliefs on treatment decisions: lipid therapy in high-risk patients

BACKGROUND

Despite clinical guidelines, many patients with hypercholesterolemia do not achieve treatment goals in clinical practice.

OBJECTIVES

This study examined physician attitudes and beliefs about hyperlipidemia and whether they are associated with lipid treatment decisions.

METHODS

This was a cross-sectional study of 107 physicians who completed a validated survey of attitudes and beliefs about hyperlipidemia and provided treatment histories for 1187 statin-treated patients with coronary heart disease (CHD) or who were CHD risk-equivalent. Logistic regressions (using generalized estimating equation) estimated the impact of patient characteristics and physician attitudes and beliefs on whether a patient received increases in the statin dose.

RESULTS

Approximately 70% of the 843 patients who were not at low-density lipoprotein cholesterol goal (<100 mg/dL) with initial statin therapy received a dose increase, although only one-half attained goal. Controlling for patient characteristics, patients whose physicians believed "close enough to goal is good enough" had 47% lower odds of having a dose increase (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.34-0.82), whereas patients whose physicians believed "statins are effective" had almost twice the odds of having a dose increase (OR, 1.78; 95% CI, 1.05-3.00).

CONCLUSIONS

Although the understanding of basic and clinical science remains fundamental, clinical guideline authors may want to consider the importance of physician attitudes and beliefs in determining translation of their guidelines into clinical practice.

Achieving National Cholesterol Education Program goals in coronary artery disease

National Cholesterol Education Program (NCEP) guidelines recommend low-density lipoprotein cholesterol (LDL-C) levels <100 mg/dL for patients with coronary artery disease (CAD) and lipid-lowering therapy if LDL-C remains >100-130 mg/dL after dietary intervention. Studies consistently report that the majority of CAD patients do not achieve NCEP goals in clinical practice; we sought to determine if our practice fared better. We performed a retrospective chart review of 600 CAD patients followed by cardiologists. The mean age was 69, and 66% of patients were male. Of persons with a cardiology clinic lipid profile (60%), most (76%) achieved an LDL-C <100 mg/dL; however, only 61% were treated to the NCEP secondary goal of non-HDL-C <130 mg/dL. Of patients not at an LDL-C goal, 81% were on lipid-lowering therapy, but only 18% were on maximal statin doses and 6% on combination therapy. We concluded that the majority of CAD patients have had recent lipid measurements and are treated according to NCEP guidelines, but many patients remain on suboptimal therapy.

Using "get with the guidelines" to improve cardiovascular secondary prevention

BACKGROUND

"Get With The Guidelines (GWTG)" was developed and piloted by the American Heart Association (AHA), New England Affiliate; MassPRO, Inc.; and other organizations to reduce the gap in the application of secondary prevention guidelines in hospitalized cardiovascular disease patients. Collaborative learning programs and technology solutions were created for the project.

THE PATIENT MANAGEMENT TOOL (PMT)

The interactive Web-based patient management tool (PMT) was developed using quality measures derived from the AHA/American College of Cardiology secondary prevention guidelines. It provided data entry, embedded reminders and guideline summaries, and online reports of quality measure performance, including comparisons with the aggregate performance of all hospitals.

LEARNING SESSIONS

Multidisciplinary teams from 24 hospitals participated in the 2000-2001 pilot. Four collaborative learning sessions and monthly conference calls supported team interaction. Best-practices sharing and the use of an Internet tool enabled hospitals to change systems and collect data on 1,738 patients.

SUMMARY AND CONCLUSIONS

The GWTG program, a template of learning sessions with didactic presentations, best-practices sharing, and collaborative multidisciplinary team meetings supported by the Internet-based data collection and reporting system, can be extended to multiple regions without requiring additional development. Following the completion of the pilot, the AHA adopted GWTG as a national program.

Review of evidence and explanations for suboptimal screening and treatment of dyslipidemia in women. A conceptual model

Screening and treatment rates for dyslipidemia in populations at high risk for cardiovascular disease (CVD) are inappropriately low and rates among women may be lower than among men. We conducted a review of the literature for possible explanations of these observed gender differences and categorized the evidence in terms of a conceptual model that we describe. Factors related to physicians' attitudes and knowledge, the patient's priorities and characteristics, and the health care systems in which they interact are all likely to play important roles in determining screening rates, but are not well understood. Research and interventions that simultaneously consider the influence of patient, clinician, and health system factors, and particularly research that focuses on modifiable mechanisms, will help us understand the causes of the observed gender differences and lead to improvements in cholesterol screening and management in high-risk women. For example, patient and physician preferences for lipid and other CVD risk factor management have not been well studied, particularly in relation to other gender-specific screening issues, costs of therapy, and by degree of CVD risk; better understanding of how available health plan benefits interact with these preferences could lead to structural changes in benefits that might improve screening and treatment.

Undocumented patient information: an impediment to quality of care

PURPOSE

Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews. We assessed the documentation of cardiac risk factors and cardiac history in the records of patients hospitalized with myocardial infarction or heart failure.

METHODS

We performed a retrospective cohort study involving direct chart audit of all consecutive hospitalizations for myocardial infarction (n = 2,109) or heart failure (n = 3,392) in Nova Scotia, Canada, from October 15, 1997, to October 14, 1998. The main outcome measures were the documentation rates for prespecified clinical items, including cardiac risk factors and history of myocardial infarction or heart failure, which were recognized as indicators of the quality of care for the conditions under study.

RESULTS

Information was not documented in a high proportion of cases, ranging from 9% (smoking) to 58% (previous history of heart failure) in charts from patients hospitalized for myocardial infarction, and from 19% (smoking) to 69% (hyperlipidemia) in charts from heart failure hospitalizations. Lack of documentation was more common in women and the elderly.

CONCLUSION

Documentation of important clinical information is poor even in the hospital charts of patients with severe conditions. This quality-of-care issue has implications for health services and outcomes research, including the development of report cards.

The surveillance of cholesterol management in the cardiac rehabilitation setting

PURPOSE

To evaluate the secondary prevention of coronary heart disease in the cardiac rehabilitation setting by quantifying the percentage of patients on lipid lowering therapy, the percentage of patients who have received diet counseling, and the percentage of patients with a lipid panel documented by discharge.

METHODS

The Web-based database of the Wisconsin Society for Cardiovascular and Pulmonary Rehabilitation, representing 1477 patients, was examined for patient outcomes. A survey was sent to programs to assess the processes in place to assist patients in managing cholesterol and reaching a low-density lipoprotein (LDL-C) goal of less than 100 mg/dL.

RESULTS

Most patients were taking cholesterol medications (median, 70.9%; 95% confidence interval [CI], 63.9-80.9). A minority of patients had an LDL-C at the goal level (median, 42.6%; 95% CI, 27.7-58.6), and a few patients had received individual dietary counseling from a registered dietitian (median, 17.9%; 95% CI, 4.8-56.2). The survey indicated that although all programs made an effort to determine cholesterol levels at cardiac rehabilitation entry, only one half of the programs required a lipid panel at discharge also.

CONCLUSIONS

There is a high degree of variation among cardiac rehabilitation programs in terms of surveillance and treatment of dyslipidemias for patients with coronary heart disease.

Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting

We evaluated the effectiveness of pharmacist-managed pharmacotherapy clinics in implementing and maximizing therapy with agents known to reduce the morbidity and mortality associated with cardiovascular disease. This was a retrospective chart review of 150 patients who were treated for coronary artery disease in primary care clinics. Appropriate treatment of hypercholesterolemia occurred in 96% of patients referred to a clinical pharmacy specialist, compared with 68% of those followed by primary care providers alone (p<0.0001). Eighty-five percent and 50%, respectively, achieved goal low-density lipoprotein (LDL) values below 105 mg/dl (p<0.0001). Appropriate therapy with aspirin or other antiplatelet or anticoagulant drugs was prescribed in 97% and 92%, respectively (p=0.146). As appropriate therapy with these agents was high in both groups, the ability to detect a difference between groups was limited. Among patients with an ejection fraction below 40%, appropriate therapy with an angiotensin-converting enzyme inhibitor or acceptable alternative was 89% and 69%, respectively (p<0.05). Twenty-seven cardiac events were documented in the clinical pharmacy group, versus 22 in the primary care group (p=0.475). Despite the relatively high percentage of patients reaching goal LDL in the primary care group, referral to clinical pharmacy specialists resulted in statistically significant increases in the number of patients appropriately treated for hypercholesterolemia and achieving goal LDL.

Cardiovascular drug utilization and its determinants in unselected medical patients with ischemic heart disease

Background: In patients with ischemic heart disease (IHD), secondary preventive drug therapy improves overall prognosis. Therefore, this study evaluated cardiovascular drug utilization in patients suffering from IHD, identified factors influencing drug utilization, and determined the prevalence of shortfalls of antithrombotic, beta-blocker, and lipid-lowering drug use. Methods: This study is based on data recorded prospectively between 1996 and 1998 in two Swiss teaching hospitals for the SAS/CHDM pharmacoepidemiologic database project. Drug utilization was evaluated in all 987 monitored medical inpatients with IHD. Results: At discharge, only 64% of patients with IHD received platelet aggregation inhibitors, 42% beta-blockers, and 26% lipid-lowering drugs. Secondary preventive drugs were more frequently administered to patients with acute myocardial infarction and less frequently in the elderly. After including other co-factors, no gender difference could be detected. Shortfalls of antithrombotic therapy occurred in 6.5--8.3% of patients and shortfalls in beta-blocker use in 9.9--23.3%. Only about half of all patients with IHD and elevated cholesterol received lipid-lowering drugs. Conclusions: Drugs for secondary prevention are prescribed to the majority of patients with IHD. However, their use could be further increased, especially in the elderly and in patients with IHD who are admitted to the hospital for reasons other than acute myocardial infarction. Lipid-lowering drugs should also be prescribed more often for patients with hypercholesterolemia.

Physician-prompting statin therapy intervention improves outcomes in patients with coronary heart disease

STUDY OBJECTIVE

To evaluate the effectiveness of a posthospital discharge intervention that prompted physicians to increase the use and effectiveness of statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) in patients with coronary heart disease (CHD).

METHODS

Participants were 612 patients with CHD who were admitted to a coronary care unit. The control group (303 patients admitted from October 1-December 31, 1998) received no follow-up intervention. The intervention group (309 patients admitted fromJanuary 1-March 31, 1999) had follow-up letters sent or phone calls made to their primary care physicians with patient-specific recommendations concerning assessment of lipid profiles and statin therapy. Over a 2-year follow-up period, assessment of lipid profiles, use of therapy, and adverse clinical outcomes were compared between the control and intervention groups.

RESULTS

At hospital discharge, there was no significant difference in the use of statins between the groups. At each reported follow-up interval, the percentages of patients having lipid profiles measured, being treated with a statin, receiving titrated dosages of a statin, and achieving low-density lipid (LDL) cholesterol goals set by the National Cholesterol Education Program (NCEP) were significantly greater in the intervention group compared with the control group (all p<0.05). At the end of the 2-year follow-up period, nearly three-fourths (72%) of the intervention group were receiving a statin, compared with 43% of the control group. In addition, 55% of the intervention group achieved their NCEP LDL goal, compared with only 10% of the control group. Recurrent myocardial infarction, hospitalization for myocardial ischemia, coronary revascularization, and cardiovascular mortality were significantly reduced in the intervention group compared with the control group (all p<0.05).

CONCLUSION

A relatively simple physician-prompting intervention significantly increased assessment of lipid status, frequency of statin use, achievement of LDL treatment goals, and titration of lipid drug dosages. In addition, the improved use of statins significantly reduced adverse cardiovascular outcomes. This intervention tool should be more broadly applied in patient populations eligible to receive these agents.

Quality improvement research on late life depression in primary care

BACKGROUND

Two million older Americans suffer from depression annually. Depression causes more functional impairment than many other common medical conditions and older adults have the highest rate of suicide in the United States. Although many of these patients fail to seek or fail to receive care for depression, the majority will be seen in primary care for the treatment of other conditions.

OBJECTIVE

To review the health services research on quality improvement for late life depression.

METHODS

Qualitative literature review.

RESULTS

During the past 30 years, multiple educational and quality improvement interventions have been designed and tested to improve the recognition and treatment of depression in primary care settings. The findings from this large body of health services research suggest that: (1) the outcome of major depression in the usual care of primary care is typically poor; this is particularly true of late life depression; (2) informational support provided to primary care physicians is necessary but insufficient to improve the outcomes of late life depression in primary care; achieving guideline-level therapy requires the substantial participation of an informed and motivated patient working in concert with a health care team and health care system designed to care for chronic conditions; (3) up to 30% of older primary care patients will fail to respond to excellent guideline-level therapy provided in primary care; and (4) the latest quality improvement efforts focus not only on the clinical skills of primary care physicians, but also on patient's self-care and on innovative strategies to improve the system of care.

CONCLUSIONS

Late life depression is often a chronic disease and outcomes research demonstrates that quality improvement efforts that focus resources on improving systems of care and the active participation of patients offer the best evidence of improved patient outcomes.

Cholesterol risk management: a systematic examination of the gap from evidence to practice

Hypercholesterolemia is a major risk factor for coronary heart disease, and data indicate that aggressive cholesterol reduction decreases mortality and morbidity associated with this disease. Many patients with hypercholesterolemia, however, are not screened, prescribed appropriate lipid-lowering therapy, or treated to target cholesterol levels. Practice patterns are particularly inadequate for those patients at highest risk for having a cardiac event. We performed a literature search to identify studies of practice patterns in the management of patients with hypercholesterolemia with regard to screening, implementing lipid-lowering therapy, and treating to lipid goals. The findings highlight the potential for substantial opportunities to improve patient outcomes. Future studies should evaluate reasons for suboptimal cholesterol management as well as provide steps to improve management.

Effect of a clinical pharmacist-managed lipid clinic on achieving National Cholesterol Education Program low-density lipoprotein goals

Despite national guidelines for treatment of hyperlipidemia, significant numbers of individuals with coronary artery disease are not treated to their National Cholesterol Education Program (NCEP) low-density lipoprotein (LDL) goals. The potential benefits of a clinical pharmacist-managed lipid clinic would be to improve rates of success in achieving these goals, improve drug adherence and compliance with therapy, and reduce cardiovascular events. All patients who had a documented history of coronary artery disease and were under the care of one cardiologist were treated in the pharmacist-managed lipid clinic. A second cardiologist provided usual care to a group of patients with coronary artery disease who served as controls. Patients in each arm were followed for a minimum of 6 months. A protocol for therapy changes in clinic patients was developed by the clinical pharmacist and approved by the cardiologist. At the end of 6 months, 69% of patients in the pharmacist-managed clinic achieved their LDL goal, compared with 50% of controls. Compliance with laboratory tests and drug regimens also improved in clinic patients. Compliance with lipid panels went from 8% 2 months before to 89% 2 months after the start of the study. At the end of 6 months compliance with laboratory work and refills was 80%. Thus the clinical pharmacist-managed clinic was highly successful in achieving NCEP goals for secondary prevention.

Impact of pharmacy counseling on compliance and effectiveness of combination lipid-lowering therapy in patients undergoing coronary artery revascularization: a randomized, controlled trial

This randomized, controlled trial evaluated the impact of personalized follow-up on compliance rates in high-risk patients receiving combination lipid-lowering therapy over 2 years. A random sample of 30 patients 7-30 days after cardiac surgery had baseline fasting low-density lipoprotein levels higher than 130 mg/dl. All patients received lovastatin 20 mg/day and colestipol 5 g twice/day. Weekly telephone contact was made with each patient for 12 weeks. Short- and long-term compliance was assessed by pill and packet counts and refill records. Compliance and lipid profile results were significantly better in the intervention group (p<0.05) up to 2 years after the start of therapy than in the control group for all parameters except high-density lipoprotein. However, this effect was not apparent during the first 12 weeks of therapy. Short-term telephone follow-up favorably affected compliance and lipid profile results up to 2 years after start of therapy.

[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]).

Secondary prevention in a cardiology group practice and hospital setting after a heart-care initiative

The American Heart Association (AHA) Consensus Panel Statement for Preventing Heart Attack and Death in Patients with Coronary Disease provides recommendations for the secondary prevention of heart disease in at-risk patients. Blackstone Cardiology Associates of Pawtucket, Rhode Island, undertook an initiative in their practice implementing secondary-prevention guidelines in patients with coronary artery disease. This retrospective study evaluates practice patterns for the management of hyperlipidemia for a cardiology group in an ambulatory and hospital setting after the institution of a physician-supervised, nurse-based disease management program. Practice patterns in patients with established coronary heart disease treated in a lipid center compared with non-lipid-center settings were evaluated. Parameters evaluated included documenting low-density lipoprotein (LDL) cholesterol, presence of lipid-lowering therapy, and achieving the National Cholesterol Education Program II (NCEP II) goal of LDL-cholesterol levels < or =100 mg/dL in patients with preexisting coronary artery disease. A total of 352 patients met inclusion criteria in the lipid-center setting and were compared with 289 non-lipid-center consecutively chosen patients. Age and gender differences were also evaluated. Inpatient medical records from a 254-bed Brown University-affiliated teaching hospital were also evaluated for lipid profile, achievement of NCEP II goal, and use of lipid-lowering medication on admission and discharge. The most recent LDL-cholesterol values of patients followed in the lipid-center and in the non-lipid-center setting of the Blackstone Cardiology Associates were compared. Blackstone Cardiology Associates consists of 4 cardiologists and 4 advanced-practice nurses. Achievement of LDL-cholesterol goal was higher in both the lipid-center and non-lipid-center settings compared with baseline. A smaller percentage of patients at goal in the lipid setting is likely due to referral bias resulting in patients with more difficult-to-manage mixed dyslipidemias and behavior-management issues ending up in the lipid center. There were no apparent sex differences at goal, and more elderly (age > or =65 years) achieved goal in the lipid clinic center. In the non-lipid-center setting, more males were at goal and had a lower mean LDL-cholesterol level.

Lipid lowering in the cardiac rehabilitation setting

PURPOSE

The authors determined the frequency and effectiveness of pharmacologic lipid lowering, guided by the recommendations of the National Cholesterol Education Program (NCEP) before and after institution of a systematic lipid assessment performed at the time of the cardiac rehabilitation entry evaluation.

METHODS

The systematic lipid evaluation included a full lipid profile and a dietary evaluation at which time an active approach to pharmacologic lipid therapy was taken. Therapy was guided by the NCEP guidelines, with the collaboration of the referring physician. The frequency of lipid therapy change (starting or changing therapy) from the baseline evaluation to a 3-month follow-up visit was the primary study outcome variable. The control group consisted of 51 patients with coronary heart disease (CHD) seen in 1995 at cardiac rehabilitation, who agreed to have their serum lipids measured in a double-blinded fashion. There was no systematic lipid lowering intervention. The intervention group consisted of 187 patients with CHD who participated in cardiac rehabilitation in 1996 to 1997.

RESULTS

At baseline, a similar percentage of patients in each group were on lipid lowering therapy: 38% (19/51) in controls versus 35% (65/187) in intervention patients. Among patients with a baseline low-density lipoprotein (LDL) cholesterol of > or = 130 mg/dL, therapy was modified in 18% (4/22) of control patients compared with 52% (35/68) of intervention patients (P < 0.05). Among patients with a baseline LDL cholesterol of > or = 160, therapy was altered in 22% (2/9) control patients compared with 72% (18/25) intervention patients (P < 0.01). In both risk strata of > or = 130 mg/dL and > or = 160 mg/dL, LDL cholesterol measures were lowered to a greater degree in the intervention group.

CONCLUSIONS

The performance of a systematic lipid review at the time of cardiac rehabilitation entry, with an active stance toward pharmacologic therapy, results in a threefold increase in pharmacologic modifications and lower LDL cholesterol values for cardiac rehabilitation participants.

Follow-up on primary prevention trials

Recent primary prevention trials demonstrated that cardiovascular morbidity and mortality benefits are not accompanied by adverse effects on overall mortality and morbidity in cohorts representing plasma cholesterol concentrations observed in the bulk of coronary artery disease. During the past year, further analyses of the West of Scotland Coronary Prevention Study have indicated that benefit requires a 25% reduction of LDL cholesterol and that such treatment is not very expensive when focussed on selected high-risk individuals. The Air Force/Texas Coronary Artery Prevention Study indicated that benefit is seen in individuals with even lower plasma lipid concentration. Although current treatment with lifestyle and lipid modifying drug management is successful in primary prevention, the unpredictable nature of coronary artery disease and the cost of drugs mitigate against direct application of drug management in persons with relatively low risk, but selective treatment should be undertaken in very high-risk settings. Future studies need to examine more specific at risk cohorts, test better targeted lipoprotein modification, test more risk factors and also examine whether changes in vascular function or markers of inflammation will predict a better outcome.