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Physicians Update

Winter 2008: Heart

Evidence Must Be at the Heart of Treatment Programs

While outcomes-research has provided information used by experts to establish consensus on optimal standards of care for patients with cardiovascular disease, that hasn’t always translated into optimal care. In fact, studies have consistently revealed sizable gaps between what the evidence shows to be the best treatment approach for a particular condition and the application of that treatment in clinical practice.

“Too often, treatment decisions are made based on anecdotal experience mixed with what the physician has read in the literature, but without regard to any systematic guidelines,” says James N. Weiss, M.D., chief of cardiology at UCLA Medical Center. “It has become apparent that many patients are not being treated with the proven therapies.”

The American College of Cardiology and American Heart Association have evidence-based treatment guidelines for most clinical conditions, but because the information is frequently updated, practitioners are not always aware of the latest recommendations, or are too busy to go through their own mental checklists to determine whether patients are on appropriate medications, Dr. Weiss notes.

At UCLA, the Division of Cardiology has responded to this problem by bringing together teams of researchers to define systematic guidelines that can be followed in the hospital to improve outcomes and ensure that clinical therapies are given to patients on a consistent basis. In addition, many of the division’s ongoing programs contribute to the research trials that determine which therapies are optimal.

The most notable of these efforts has also helped to improve treatment for coronary-artery disease across the country. CHAMP (Cardiovascular Hospitalization Atherosclerosis Management Program) was started in 1994 at UCLA by Gregg C. Fonarow, M.D., director of the Ahmanson- UCLA Cardiomyopathy Center, to create a hospital-based system to reduce the risks and consequences of heart disease through improved use of secondary prevention treatments. CHAMP served as a performance-improvement system by developing a protocol to ensure proper implementation of safe and effective patient care and provision of key evidence-based therapies and counseling. Among its innovations, CHAMP was the first program to start patients on statins and other important protective medications during hospitalization.

“We had become aware that there were large treatment gaps—a tremendous proportion of patients who should have been receiving therapies recommended by the guidelines were not receiving them when they left the hospital, and they were coming back with recurrent events that could have been prevented had their care been different,” says Dr. Fonarow. “CHAMP was a way of developing a system to ensure reliable care no matter which physician was caring for a patient by creating safety checks, redundancies and prompts.” Among other things, CHAMP found that hospitalization serves as a “teachable moment”; when therapies are started in the hospital they are more likely to be adhered to than when they are begun during outpatient care.

CHAMP became the forerunner for what is now the American Heart Association’s Get With the Guidelines (GWTG) program. Approximately 1,400 U.S. hospitals participate in GWTG, for which Dr. Fonarow is the national chair. Studies of GWTG have replicated CHAMP’s initial findings on improvements in quality of care and outcomes in hospitals large and small, teaching and non-teaching, rural and urban.

“This has changed the face of cardiovascular care across the country,” says Dr. Fonarow. CHAMP continues to integrate new therapies as evidence indicates that they should be routinely applied. In addition, Dr. Fonarow’s team has taken the CHAMP platform and applied it to heart failure through a program called OPTIMIZE Heart Failure, which was used in 259 U.S. hospitals and has served as a precursor for what is now the American Heart Association’s Get With The Guidelines-Heart Failure program. The same principles are also being applied for stroke treatment. The platform is also being used to test the impact of using evidence-based protocols for the treatment of heart disease in women. Karol Watson, M.D., Ph.D., UCLA cardiologist, notes that women with heart disease tend to present differently than men. “In men, the symptoms are typically what we call classic—they are undeniable and very difficult to ignore, because often it’s like an elephant has stomped on their chest and they have unrelenting pain,” she says. “While chest pain is a common feature for women, more common are somewhat nonspecific symptoms such as fatigue and shortness of breath, which makes it easier to overlook.”

Coronary angiography, the gold standard for diagnosing the disease in men, appears to be less effective in diagnosing women, Dr.Watson adds. Evidence is also emerging that heart disease is more likely to affect the small vessels in women than in men; this may mean that in some cases the medications indicated would differ.Women might respond better to ACE inhibitors, which improve endothelial function, than to medications that dilate the blood vessels, Dr.Watson suggests. “Studies have shown that microvascular disease is associated with as poor an outcome in women as macrovascular disease,” she says. “Disease of the large vessels can be diagnosed with an angiogram, but not disease of the tiny vessels. So we need to find other ways to find the disease, as well as looking at whether therapies that improve microvascular function will improve outcomes in these patients.”

In addition to applying what is already known about treatment of women with heart disease, Dr. Watson’s program is enrolling patients in an effort to build on the knowledge base and show whether evidence-based treatment will make a difference. Even simple questions such as whether cholesterol- and blood pressure-lowering therapies are beneficial for women, in whom they haven’t been tested specifically, must be addressed, Dr. Watson notes.

Recommended Reading

Fonarow GC, et al. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med. 2007;167:1493-502.

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