Novel pathway for sudden cardiac death prevention

Success in implementing a hospital-wide evidence-based clinical pathways system for the management of cardiac patients: the ACAP program experience

There is robust evidence to support the concept that critical pathways, derived from evidence-based guidelines, are an effective strategy for bridging the gap between published guidelines and clinical practice. It was with this idea in mind that in 2004 we developed an innovative novel program at our institution, that is, the "Advanced Cardiac Admission Program." The Advanced Cardiac Admission program consists of tools and strategies for implementing American College of Cardiology or American Heart Association guidelines into daily clinical practice. The program is composed of 8 novel critical pathways for the management of cardiac patients. In this article, we describe our experience in successfully implementing this program at our institutions.

Implementing a pathway for the management of acute coronary syndrome leads to improved compliance with guidelines and a decrease in angina symptoms

We describe our experience with the Advanced Cardiac Admission Program (ACAP) at our institution. The ACAP program is a hospital-wide implementation of critical pathways-based management of all cardiac patients. Data review of patients admitted for acute coronary syndromes from the ACAP-PAIN database and a comparative study of outcomes before and after implementation of the pathways-based assessment and treatment protocols. In the pre-ACAP and post-ACAP patient groups, antiplatelet use at admission improved from 50% to 75% (p<.01), ACE-I use improved from 32% to 54% (p<.0001), statins use increased from 35% to 62% (p<.0001), and smoking cessation awareness increased from 15% to 86% (p<.0001). At 1-year follow-up, 84% of patients with CAD were treated with statins, and 47% had LDL cholesterol <100 mg/dL, compared with 20% and 9%, respectively, with conventional treatment before ACAP implementation (p<.0001). Recurrent angina symptoms and nonfatal myocardial infarction rates decreased from 28.5% to 13% (p = .02), and 15% to 5% (p = 0.03), respectively. Pathway-based programs like ACAP significantly enhance administration of guidelines-based cardioprotective medications both during hospital stay and at 1-year follow-up.

Strategies for the prevention and treatment of sudden cardiac death

Cardiovascular diseases account for 40% of all deaths in the West. Sudden cardiac death (SCD) is a major health problem affecting over 300,000 patients annually in the United States alone. Presence of coronary artery disease (CAD), usually in the setting of diminished left ventricular ejection fraction, is still the single major risk factor for SCD. Additionally, acute myocardial ischemia, structural cardiac defects, anomalous coronary arteries, cardiomyopathies, genetic mutations, and ventricular arrhythmias are all attributed to SCD, demonstrating the perplexity of this condition. With the recent advancements in cardiovascular medicine, the incidence of SCD is expected to increase steeply as the prevalence of CAD and heart failure is uprising in general population. Considering SCD, the major challenge confronting contemporary cardiology, multiple strategies for prevention against SCD have been developed. β-blockers have been shown to reduce the risk of SCD, whereas implantable cardioverter-defibrillator devices are found to be effective at terminating the malignant arrhythmias. In recent years, multiple clinical trials were carried out to identify patients who may benefit from preventive intervention, including medical therapy and automatic cardioverter-defibrillator implantations. This review article provides insight into the advanced strategies for the prevention and treatment of SCD based on the data available in medical literature to date.

Pathway for the management of survivors of out-of-hospital cardiac arrest

The estimated number of out-of-hospital care arrest cases is about 300,000 per year in the United States. Two landmark studies published in 2002 demonstrated that the use of therapeutic hypothermia after cardiac arrest decreased mortality and improved neurologic outcome. Based on these studies, the International Liaison Committee on Resuscitation and the American Heart Association recommended the use of therapeutic hypothermia after cardiac arrest. Therapeutic hypothermia is defined as a controlled lowering of core body temperature to 32 degrees C to 34 degrees C. This temperature goal represents the optimal balance between clinical effect and cardiovascular toxicity. Therapeutic hypothermia does require resources to implement-including device, close nursing care, and monitoring. It is important to select patients who have potential for benefit from this technique which is a limited resource and carries potential complications. A collaborative team approach involving physicians and nurses is critical for successful development and implementation of this kind of a protocol. In 2004, the "Advanced Cardiac Admission Program" was launched at the St. Luke's Roosevelt Hospital Center of Columbia University in New York. The program consists of a series of projects, which have been developed to bridge the gap between published guidelines and implementation during "real world" patient care. In this article, we are reporting our latest project for the comprehensive management of survivors of out-of-hospital cardiac arrest. The pathway is divided into 3 steps: Step I, From the field through the emergency department into the cardiac catherization laboratory and to the critical care unit; Step II, Induced invasive hypothermia protocol in the critical care unit (this step is divided into 3 phases: 1, invasive cooling for the first 24 hours; 2, rewarming; 3, maintenance); Step III, Management post the rewarming phase including the recommendation for out-of-hospital therapy and the ethical decision to define goal of care. We hope that this novel pathway will bridge the gap between the complex guidelines and the actual clinical practice and will improve the survival and neurologic condition of patients suffering cardiac arrest.