Professional Documents
Culture Documents
Nathan D. Wong, PhD, FACC, FAHA Professor and Director Heart Disease Prevention Program Division of Cardiology University of California, Irvine, CA USA President, American Society for Preventive Cardiology
Scientific Statements
- increase knowledge and awareness by healthcare professionals of effective, stateof-the art science related to the causes, prevention, detection, or management of cardiovascular diseases and stroke. - represent the consensus of the leading experts in cardiovascular disease and stroke. - undergo blinded peer review and are reviewed and approved by the AHA Science Advisory and Coordinating Committee (SACC), the highest scientific body of the AHA.
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Guidelines
The Institute of Medicine defines a guideline as systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. The AHA often develops practice guidelines in conjunction with the American College of Cardiology (ACC), but also may develop them alone or in partnership with other organizations as appropriate. All guidelines adhere to the levels of evidence and classes of recommendation as established by the ACC/AHA Guidelines Task Force. All guidelines undergo peer review and are reviewed and approved by the AHA SACC.
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Procedure or treatment should NOT be performed or administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Class I
Recommendation that procedure or treatment is useful/ effective Sufficient evidence from multiple randomized trials or metaanalyses
Class IIa
Recommendation in favor of treatment or procedure being useful/ effective Some conflicting evidence from multiple randomized trials or metaanalyses
Class IIb
Recommendation s usefulness/ efficacy less well established Greater conflicting evidence from multiple randomized trials or metaanalyses
Class III
Recommendation that procedure or treatment not useful/ effective and may be harmful
Class I
Recommendation that procedure or treatment is useful/ effective Limited evidence from single randomized trial or nonrandomized studies
Class IIa
Recommen-dation in favor of treatment or procedure being useful/ effective Some conflicting evidence from single randomized trial or nonrandomized studies
Class IIb
Recommendations usefulness/ efficacy less well established Greater conflicting evidence from single randomized trial or nonrandomized studies
Class III
Recommen-dation that procedure or treatment not useful/effective and may be harmful Limited evidence from single randomized trial or nonrandomized studies
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Class I
Recommendation that procedure or treatment is useful/ effective Only expert opinion, case studies, or standard-ofcare
Class IIa
Recommendation in favor of treatment or procedure being useful/effective Only diverging expert opinion, case studies, or standard-of-care
Class IIb
Recommendations usefulness/ efficacy less well established Only diverging expert opinion, case studies, or standard-of-care
Class III
Recommendation that procedure or treatment not useful/effective and may be harmful Only expert opinion, case studies, or standard-of-care
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Numerator = Patients with assessment of diet and physical activity occurred in the past 2 years Denominator = Patients aged 8-80 years at beginning of assessment period
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Numerator = Patients who were advised to eat a healthy diet at least once in the past 2 years Denominator All patients 18 to 80 years of age at start of the measurement period
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Numerator = Patients who were advised at least once within the past 2 years to engage in regular physical activity Denominator All patients 18 to 80 years of age at start of the measurement period
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Numerator = Patients who were queried about tobacco use 1 or more times in the past 2 years
Denominator All patients 18 years of age or over at start of the measurement period
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Numerator = Patients identified as tobacco users who received cessation intervention Denominator = All patients aged 18 years and over at start of measurement period identified as tobacco 19 users
Numerator = Patients for whom weight and BMI and/or WC is documented at least once in the last 2 years Denominator = All patients 18-80 years of age at start of measurement period
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Weight Management
Numerator = All patients who were counseled on weight management at least once within the past 2 years
Denominator = All patients 18-80 years of age at start of measurement period with BMI >30 or WC >102 cm (men) or >88 cm (women)
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Numerator = Patients for whom blood pressure measurement was recorded at least once in the past 2 years Denominator = All patients aged 18-80 years at
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Numerator: Patients aged 18-80 years of age with HTN who had a recorded BP reading <140/90 mmHg or who were prescribed 2+ medications Denominator: Patients with HTN diagnosed for at least 6 months
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Numerator = Patients with at least 1 fasting lipid profile performed within the past 5 years
Denominator = Men aged 35-80 or Women aged 45-80 with at least 1 risk factor, 2+ visits
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Numerator = Patients whose most recent LDL-C (mg/dl) was <190 (<10% risk women), <160 (<10% low risk men), <130 (10-20% risk), <100 (>20% risk), or prescribed maximal lipid therapy Denominator = Patients with a fasting lipid profile and risk assessment
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Numerator (quality improvement only): patients for whom 10-year risk of CHD is recorded at least once in the last 5 years
Denominator: Men aged 35-80 and women 45-80 free of CHD but with at least one risk factor
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Aspirin use
Numerator ( internal quality improvement only): men aged 35-80 or women 45-80 advised to use aspirin
Denominator: All men 35-80 or women 45-80 without CVD but with estimated 10-year CHD risk >=20%
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AHA Secondary Prevention for Patients with Coronary Artery and Other Atherosclerotic Vascular Disease
Introduction
Since the 2001 update of the AHA/ACC consensus statement on secondary prevention, important evidence from clinical trials has emerged that further supports and broadens the merits of aggressive risk reduction therapies This growing body of evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves the quality of life The secondary prevention patient population includes those with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease and carotid artery disease.
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Therapy to reduce recurrent cardiovascular events and decrease cardiovascular mortality in patients with established atherosclerotic vascular disease Patients covered include those with established coronary and other atherosclerotic vascular disease, including peripheral arterial disease, atherosclerotic aortic disease and carotid artery disease Individuals with sub-clinical atherosclerosis and patients whose only manifestation is diabetes are covered in other guidelines
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This approach strengthens the evidence-based foundation for therapeutic application of these guidelines. The committee acknowledges that in many trials there is under-representation of ethnic minorities, women, and the elderly.
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Assist by counseling and developing a plan for quitting. Arrange follow-up, referral to special programs, or pharmacotherapy (including nicotine replacement and bupropion. Urge avoidance of exposure to environmental tobacco smoke at work and home.
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Blood pressure 120/80 mm Hg or greater: Initiate or maintain lifestyle modification: weight control, increased physical activity, alcohol moderation, sodium reduction, and increased consumption of fresh fruits vegetables and low fat dairy products Blood pressure 140/90 mm Hg or greater (or 130/80 or greater for chronic kidney disease or diabetes) As tolerated, add blood pressure medication, treating initially with beta blockers and/or ACE inhibitors with addition of other drugs such as thiazides as needed to achieve goal blood pressure
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Risk Category
LDL-C and nonHDL-C Goal <100 mg/dL if TG > 200 mg/dL, non-HDL-C should be < 130 mg/dL <70 mg/dL, non-HDL-C < 100 mg/dL
High risk: CHD or CHD risk equivalents (10-year risk >20%) and Very high risk: ACS or established CHD plus: multiple major risk factors (especially diabetes) or severe and poorly controlled risk factors
All patients
ATP=Adult Treatment Panel, CHD=Coronary heart disease, LDL-C=Low-density lipoprotein cholesterol, TLC=Therapeutic lifestyle changes Grundy, S. et al. Circulation 2004;110:227-39.
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Start dietary therapy (<7% of total calories as saturated fat and <200 mg/d cholesterol) Adding plant stanol/sterols (2 gm/day) and viscous fiber (>10 mg/day) will further lower LDL
I IIa IIb III
Promote daily physical activity and weight management. Encourage increased consumption of omega-3 fatty acids in fish or 1 g/day omega-3 fatty acids in capsule form for risk reduction.
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*Trans fatty acids also raise LDL-C and should be kept at a low intake. Note: Regarding total calories, balance energy intake and expenditure to maintain desirable body weight.
ATP=Adult Treatment Panel Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.
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If on-treatment LDL-C > 100 mg/dL, intensify LDL-lowering drug therapy (may require LDL lowering drug combination) If baseline is LDL-C 70 to 100 mg/dL, it is reasonable to treat to LDL < 70 mg/dL
When LDL lowering medications are used, obtain at least a 30-40% reduction in LDL-C levels.
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If TG are > 500 mg/dL, therapeutic options to prevent pancreatitis are fibrate or niacin before LDL lowering therapy; and treat LDL-C to goal after TG-lowering therapy. Achieve non-HDL-C < 130 mg/dL, if possible
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Assess risk with a physical activity history and/or an exercise test, to guide prescription
I IIa IIb III
Encourage 30 to 60 minutes of moderate intensity aerobic activity such as brisk walking, on most, preferably all, days of the week, supplemented by an increase in daily lifestyle activities Advise medically supervised programs for high-risk patients (e.g. recent acute coronary syndrome or revascularization, HF)
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If waist circumference (measured at the iliac crest) >35 inches in women and >40 inches in men initiate lifestyle changes and consider treatment strategies for metabolic syndrome as indicated. The initial goal of weight loss therapy should be to reduce body weight by approximately 10 percent from baseline. With success, further weight loss can be attempted if indicated.
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*BMI is calculated as the weight in kilograms divided by the body surface area in meters2. Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.
Vigorous modification of other risk factors (e.g., physical activity, weight management, blood pressure control, and cholesterol management as recommended). Coordinate diabetic care with patients primary care physician or endocrinologist. )
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Aspirin Recommendations
I IIa IIb III
Start and continue indefinitely aspirin 75 to 162 mg/d in all patients unless contraindicated For patients undergoing CABG, aspirin (100 to 325 mg/d) should be started within 48 hours after surgery to reduce saphenous vein graft closure Post-PCI-stented patients should receive 325 mg per day of aspirin for 1 month for bare metal stent, 3 months for sirolimus-eluting stent and 6 months for paclitaxel-eluting stent
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Clopidogrel Recommendations
for post ACS or post PCI with stent placement patients for up to 12 months for post PCI-stented patients >1 month for bare metal stent, >3 months for sirolimus-eluting stent >6 months for paclitaxel-eluting stent
*Clopidogrel is generally given preference over Ticlopidine because of a superior safety profile
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Anticoagulation Recommendations
Manage warfarin to international normalized ratio 2.0 to 3.0 for paroxysmal or chronic atrial fibrillation or flutter, and in post-MI patients when clinically indicated (e.g., atrial fibrillation, LV thrombus.)
Use of warfarin in conjunction with aspirin and/or clopidogrel is associated with increased risk of bleeding and should be monitored closely
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Use in all patients with LVEF < 40%, and those with diabetes or chronic kidney disease indefinitely, unless contraindicated
I IIa IIb III
Among lower risk patients with normal LVEF where cardiovascular risk factors are well controlled and where revascularization has been performed, their use may be considered optional
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Use in patients who are intolerant of ACE inhibitors with HF or post MI with LVEF less than or equal to 40%. Consider in other patients who are ACE inhibitor intolerant.
ACE=Angiotensin converting enzyme inhibitor, LVEF=Left Ventricular Ejection fraction, HF=Heart failure, MI=Myocardial infarction
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Use in post MI patients, without significant renal dysfunction or hyperkalemia, who are already receiving therapeutic doses of an ACE inhibitor and beta blocker, have an LVEF < 40% and either diabetes or heart failure
*Contraindications include abnormal renal function (creatinine >2.5 mg/dL in men or >2.0 mg/dL in women) and hyperkalemia (K+ >5.0 meq/L)
ACE=Angiotensin converting enzyme inhibitor, LVEF=Left Ventricular Ejection fraction, MI=Myocardial infarction
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b-blocker Recommendations
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b-blocker Recommendations
I IIa IIb III
Start and continue indefinitely in all post MI, ACS, LV dysfunction with or without HF symptoms, unless contraindicated. Consider chronic therapy for all other patients with coronary or other vascular disease or diabetes unless contraindicated.
*Precautions but still indicated include mild to moderate asthma or chronic obstructive pulmonary disease, insulin dependent diabetes mellitus, severe peripheral arterial disease, and a PR interval >0.24 seconds.
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Influenza Vaccination
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2001 Outcome Sciences, Inc.
* 97 9796 95 93
83 79
8787
* * * 91
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64656567 68
73 6770
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70 57
* 7675
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Aspirin
Lipid Rx
Smoking Cessation
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Evidence confirms that aggressive comprehensive risk factor management improves survival, reduces recurrent events and the need for interventional procedures, and improves the quality of life for these patients.
Every effort should be made to ensure that patients are treated with evidence-based, guideline recommended, life-prolonging therapies in the absence of contraindications or intolerance.
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Issue/Challenge Patients hospitalized with cardiovascular event are at particularly high risk for recurrent events, hospitalizations, and cardiovascular death. Fortunately, there are a number of evidence based and highly effective therapies which can significantly improve acute long-term care outcomes and reduce recurrent events.
While the AHA, ACC, and ASA Guidelines provide evidence-based recommendations for cardiovascular care, adherence to these guidelines is both incomplete and highly variable.
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Contracts
416 431 1318 2165
Patient Records
547,512 287,826 1,006,002 1,978,228
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50.0% 40.0% 30.0% 20.0% 10.0% 0.0% ASA within 24 Hours Baseline Current 82.1% 91.5% ASA at Discharge 83.3% 94.2% Beta Blockers at Discharge 77.9% 94.1% ACEI or ARB at D/C for LVSD 68.8% 92.6%
Lipid Lowering Therapy at D/C for LDL > 100 72.1% 91.6%
Composite 100% Performance Measure Compliance Measure 76.9% 92.7% 56.1% 85.8%
Performance Measure
July 2009
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60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Discharge Instructions Baseline Current 69.7% 89.5%
July 2009
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tPA < 3hr with Arrival < 2hr after Onset 27.6% 67.5%
Antithrombotic Tx Lipid Lowering Anticoag. Tx at at Therapy at D/C for Discharge for Afib Discharge LDL > 100 92.7% 97.2% 52.9% 93.6% Performance Measure 39.7% 84.0%
Baseline Current
July 2009
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GWTG Publications
2009 through 8/2/09: 13 Published Manuscripts (4 HF, 5 CAD, 3 Stroke, 1 CAD/HF) 23 Abstracts presented at Conferences (ISC 10, ACC 6, QCOR 7, HFSA 0) Snapshot of GWTG papers in process: 23 Manuscripts: 12 pending Journal decision, 11 in process to Journal submission 18 Abstracts: 8 pending acceptance at AHA 2009 conference, 10 in process to manuscript 32 Total Research Proposals in Queue 2008 Results: 20 Published Manuscripts (5 HF, 10 CAD, 5 Stroke) 2007 Results: 4 Published Manuscripts (1 HF, 3 CAD)
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Future Impact: Advancing Healthcare Largest national hospital-based program dedicated to quality of care improvement for patients with CVD Participating hospitals have demonstrated greater adherence to national guideline-recommended therapies compared to other US hospitals publicly reporting data at the same time (proven framework) With the possibility of such dramatic outcomes, helping healthcare professionals implement guidelines presents a great opportunity to improve the health of patients now and in the future.
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