Transcript Rationale and Design of the Cardiac Hospitalization Atherosclerosis

Rationale and Design of the Cardiac
Hospitalization Atherosclerosis
Management Program (CHAMP) at the
University of California Los Angeles
Gregg C. Fonarow, MD and Anna Gawlinski, DNSc
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Background
• Consistent and compelling clinical trial evidence has
demonstrated that risk-factor modification and treatment can
markedly decrease the risk of future coronary events and
prolong survival in patients with documented CAD.
• Despite this clear and consistent evidence, secondaryprevention medical therapies are underutilized in patients
receiving conventional care.
• To address this issue, a Cardiac Hospitalization Atherosclerosis
Management Program (CHAMP), was established and
implemented at UCLA Medical Center starting in 1994.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Program Overview (1)
• The Cardiac Hospitalization Atherosclerosis Management
Program (CHAMP) focused on initiation of:
– aspirin
– cholesterol-lowering therapy (statins) titrated to achieve an LDL-C of
< 100 mg/dL
– beta-blocker
– ACEI
• This was done in conjunction with diet, exercise and smoking
cessation counseling before hospital discharge in patients with
established coronary artery disease
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Program Overview (2)
• Implementation of CHAMP involved the use of:
–
–
–
–
a focused treatment guideline
standardized admission orders
educational lectures by local thought leaders
tracking/reporting of treatment rates
• To assess the impact of the program, treatment rates
and clinical outcomes were compared in patients
discharged in the 2-year period before and after
CHAMP was implemented.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (1)
• Aspirin
– Patients should continue on 81-325 mg aspirin/day indefinitely after
discharge.
• Cholesterol-Lowering Medications:
– Patients with CAD should be started on an HMG-CoA reductase
inhibitor to lower cholesterol and treat the underlying atherosclerosis
disease process. Starting dose should be the dose estimated to
achieve and LDL < 100 mg/dL based on the lipid panel.
• Beta Blockers:
– These agents should be considered in all patients with CAD, because
they reduce the risk of MI and make it more likely that a patient will
survive an infarction. Use target doses as clinically tolerated.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (2)
• ACE Inhibitors:
– These agents have potent vascular and cardiac protective effects.
These agents are potentially indicated in all patients with
atherosclerosis. All patients with myocardial infarction without
contraindications should be started on ACEIs within 24 hours and
treated long term. Use target doses.
• Nitrates:
– These agents should be considered second-line agents after bblockers for the symptomatic control or angina. There is no long term
data showing that nitrates improve prognosis in patients with CAD, so
their use is simply for symptom relief.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (3)
• Calcium Antagonists:
– These agents decrease chest pain but do not decrease the risk of a
cardiac event or improve survival. They should, in general, not be
prescribed to patients with known CAD.
• Antiarrhythmic Agents:
– Type I antiarrhythmic agents increase the risk of sudden death in
patients with CAD. These agents should be avoided in all patients
with CAD except those with implantable cardioverter defibrillators or in
whom the risk/benefit ratio has been carefully considered.
Amiodarone should be considered the only safe antiarrhythmic agent
in patients with CAD.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (4)
• Exercise:
– Patients should receive specific instructions for a daily aerobic exercise
program. Either a home-based program or a supervised cardiac
rehabilitation can be recommended. This is an essential component of the
management of patients with CAD and is highly effective in preventing
subsequent cardiac events.
• Smoking Cessation:
– Particular attention should be paid to smoking cessation as patients who
continue to smoke after presenting with unstable angina have 5.4 times the
risk of death from all causes compared with patients who stop smoking.
Patients should be offered intensive smoking cessation during
hospitalization. This should include both physician and nurse counseling
focusing on relapse prevention.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (5)
• Diet:
– Studies with statins that have demonstrated reduction in mortality, have
utilized these medications in conjunction with dietary counseling. Patients
and family members, if available, should receive counseling on the NCEP
Step 2 Diet during the hospitalization. Information on the outpatient dietary
modification programs available should also be provided.
• Patient Education:
– The patient and his or her family member or advocate should be instructed
on the use of medications and monitoring of symptoms. The purpose, dose,
and major side effects of each medication prescribed should be explained.
Written medication sheets and a medication schedule should be provided
along with instructions on what to do if either persistent side effects or
recurrent symptoms occur.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (6)
• Follow-up:
– Continuation of the therapies targeting the underlying atherosclerosis
disease process markedly improves clinical outcome in patients with
atherosclerosis.
– The continued beneficial therapies prescribed should be strongly
reinforced during patient follow-up.
– A fasting lipid panel should be obtained at 6 weeks to evaluate
whether target lipid levels have been achieved and to guide
cholesterol-lowering medication dosing adjustments.
Am J Cardiol 2000;85:10A-17A
CHAMP Algorithm for Patients with Clinically Evident Atherosclerosis
Coronary
Carotid
Peripheral
Clinical
Ultrasound
Stress Test
Angiographic
Atherosclerosis
Admission Lipid Panel, LFTs
Inpatient Hospitalization
Initial Outpatient Encounter
Aspirin, Beta Blocker, ACEI,
HMG CoA Reductase Inhibitor
Exercise and Dietary Counseling
LDL > 100 mg/dL
LDL < 100 mg/dL
Advance Dose and/or
Add Niacin, Resin
Continue Treatment
Recheck in 3-6 months
Recheck in 6 weeks
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Safety of Initiating Statins During
Hospitalization
Primary Diagnosis
Unstable angina
Acute MI
Chest pain
PTCA
Heart failure
CABG
Total
n
224
302
326
340
371
216
1,779
Admit
Statin Rx, %
14
8
15
8
22
16
14
Discharge
Statin, Rx, %
82
86
74
92
76
68
80
Abnormal
LFT*
Rehosp
due to Rx
1
0
0
0
2
0
3/1,423
0
0
0
0
0
0
0/1,423
*LFT = liver function tests > 3 times control requiring discontinuation of therapy
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medication Utilization Rates at Discharge
Discharge Therapy
Pre-CHAMP
(1992-1993)
(n=256), %
Aspirin
b-blocker
Nitrate
Calcium antagonists
ACE inhibitors
HMG-CoA RI
78
12
62
68
4
6
Am J Cardiol 2000;85:10A-17A
Post-CHAMP
(1994-1995)
(n=302), %
92
61
34
12
56
86
p value
<0.001
<0.001
<0.001
<0.0001
CHAMP ~ Medication Utilization Rates and LDL Levels at
One Year Post Hospital Discharge
Pre-CHAMP
(1992-1993)
Cholesterol-lowering medication
LDL < 100 mg/dL
10%
6%
Post-CHAMP
(1994-1995)
91%*
58%*
p value
<0.0001
<0.0001
*The impact of this increased treatment utilization on clinical outcomes is currently
being analyzed
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Summary
• The initial observations with CHAMP have demonstrated that CAD riskfactor modification and treatment can be systematically integrated into the
treatment provided during cardiac hospitalization utilizing existing
resources and medical personnel and that they appear to be considerably
more effective than conventional guidelines and care.
• The inpatient setting can provide an important opportunity to initiate
secondary-prevention medical therapies in patients hospitalized with
CAD, presumably impacting the risk of future coronary events and
prolonging life in the large number of CAD patients hospitalized each
year.
Am J Cardiol 2000;85:10A-17A