The gap between knowledge and practice in the treatment and prevention of cardiovascular disease

The prevalence, awareness and treatment of high low density lipoprotein-cholesterol in korean adults without coronary heart diseases - the third Korea national health and nutrition examination survey, 2005 -

BACKGROUND AND OBJECTIVES

The purpose of this study was to estimate the prevalence, awareness and treatment of high low density lipoprotein-cholesterol (LDL-C) level in Korean adults without coronary heart disease.

SUBJECTS AND METHODS

National representative cross-sectional surveys, data of 5248 Korean adults (2246 men and 3002 women) aged between 20 and 79 years from the Third Korea National Health and Nutrition Examination Survey (KNHANES III, 2005) was used. High LDL-C level was defined with the risk prediction algorithm published by the National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III).

RESULTS

The prevalence of the Korean adults with high LDL-C level who need therapeutic lifestyle changes was 19.9%, treatment with lipid-lowing medication was 2.1% and awareness of this condition was 7.9%. Meanwhile, the prevalence of the Korean with very high LDL-C level who should be considered for drug therapy was 13.5%, treatment with lipid-lowing medication was 2.7% and awareness of this condition was 8.1%. Overall, 47.9% (60.3% in male and 39.1% in female) of participants had a single lipid disorder (high LDL-C, high triglycerides: ≥200 mg/dL, low high density lipoprotein-cholesterol: <40 mg/dL), whereas 15.5% (23.5% in male and 9.7% in female) had at least two. Only 1.9% (2.8% in male and 1.2% in female) of all participants had all three lipid abnormalities as defined.

CONCLUSION

These findings indicate that continuous efforts are needed to increase awareness and treatment of high LDL-C level in our population to prevent cardiovascular disease.

Regional cardiac resuscitation systems of care

PURPOSE OF REVIEW

Out-of-hospital cardiac arrest (OOHCA) is a common public health problem. Regional systems of care have improved provider experience and patient outcomes for those with ST-elevation myocardial infarction and life-threatening traumatic injury. We review evidence of the effectiveness of regional cardiac resuscitation systems and describe preliminary recommended elements of such systems.

RECENT FINDINGS

There is large and important regional variation in survival among patients treated with OOHCA by emergency medical services, or among patients transported to the hospital after return of spontaneous circulation (ROSC). Most regions lack a well coordinated approach to postcardiac arrest care. There is little evidence to show small increases in transport time or distance have an adverse impact on survival, so bypassing closer hospitals may be feasible. Hospitals that have facilities to provide a comprehensive package of postresuscitation care including percutaneous coronary intervention and therapeutic hypothermia appear to have better survival but further studies are needed. A well defined relationship between increased volume of patients or procedures of individual providers and hospitals and better outcomes has been observed for several clinical disorders and there are suggestions that this may also be true for patients with ROSC after cardiac arrest.

SUMMARY

Many more people could survive OOHCA if regional systems of cardiac resuscitation were established. The time has come to implement such systems whenever feasible.

Barriers to and strategies for effective blood pressure control

There are major differences between the current knowledge of the treatment of cardiac conditions derived from evidence-based medicine and the widespread application of this knowledge. This is particularly true in the treatment of hypertension. Hypertension is the most common chronic cardiovascular condition, affecting more than 50 million Americans and approximately 1 billion individuals worldwide. However, many hypertensive patients are not receiving treatment, and of those that are, many are not adequately controlled. There is evidence that there are methods to improve blood pressure control and improve compliance with expert recommendations for the treatment of hypertension. These methods range from local initiatives such as academic detailing to national performance measures as have been developed by the US Department of Veterans Affairs. A challenge for the future will be to identify and broadly apply these and other programs to improve the quality and efficiency of hypertensive treatment.

Reinforcement as a means for quality improvement in management of coronary syndromes: adherence to evidence-based medicine

OBJECTIVE

To study the effect of reinforcement as a quality improvement intervention in the evidence-based management of the coronary syndromes.

METHODS

In the pre-intervention phase, the charts of 140 consecutive patients with ICD-9 codes 410-414 for coronary syndromes were reviewed for measurement of total cholesterol on admission and fasting low density lipoprotein (LDL) cholesterol, implementation of aspirin therapy on admission, beta-blockers' use during hospitalization, and treatment with angiotensin converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction. Reinforcement was used as an intervention for quality improvement. All personnel of Division of Cardiology including nursing staff, medical residents, cardiology fellows, and attending physicians were reinforced to adhere to the evidence-based management. In the post-intervention phase, charts of 140 consecutive patients with ICD-9 codes 410-414 for coronary syndromes were reviewed to assess the improvement in the same quality of care parameters.

RESULTS

By reinforcement, a significant improvement was noted in all quality of care parameters studied. Proportion of patients who had total cholesterol measured on admission increased from 78% to 92% (P<0.005), and those who had fasting LDL cholesterol measured increased from 22% to 70% (P<0.0001). Use of aspirin at admission (in 74% of patients pre- vs. 80% of patients post-intervention, P<0.05), beta-blockers during hospitalization (in 62% of patients pre- vs. 78% of patients post-intervention, P<0.001), and ACE inhibitors in patients with left ventricular systolic dysfunction (in 58% of patients pre- vs. 89% of patients post-intervention, P<0.001) improved significantly after reinforcement to the medical personal.

CONCLUSION

Reinforcement to adhere to the evidence-based management results in a significant improvement in the quality of care provided to the patients with coronary syndromes.