cardiovascular risk factor overview and management

New and Evolving Concepts in Cardiovascular Disease

Prevention and Management

Nathan D. Wong, PhD, FACC

Professor and Director

Heart Disease Prevention Program

University of California, Irvine

Most Myocardial Infarctions Are Causedby Low-Grade Stenoses

Pooled data from 4 studies: Ambrose et al, 1988; Little et al, 1988; Nobuyoshi et al, 1991; and Giroud et al, 1992.(Adapted from Falk et al.)

Falk E et al, Circulation, 1995.

(Adapted from Glagov et al.)(Adapted from Glagov et al.)

Coronary RemodelingCoronary Remodeling

NormalNormalvesselvessel

MinimalMinimalCADCAD

ProgressionProgression

Compensatory expansionCompensatory expansionmaintains constant lumenmaintains constant lumen

Expansion Expansion overcome:overcome:

lumen narrowslumen narrows

SevereSevereCADCAD

ModerateModerateCADCAD

Glagov et al, Glagov et al, N Engl J MedN Engl J Med, 1987., 1987.

Women and Heart Disease• 1 in 2-3 women die of CHD, but only

4% fear of dying of CHD

• 1 in 27 women die of breast cancer, but 40% fear of dying of breast cancer

• 2/3 of women have at least 1 CHD risk factor, 52% over age 45 have hypertension, 40% over age 55 have high cholesterol

Major Risk Factors

• Cigarette smoking• Elevated total or LDL-cholesterol• Hypertension (BP 140/90 mmHg or on

antihypertensive medication)• Low HDL cholesterol (<40 mg/dL)† • Family history of premature CHD

– CHD in male first degree relative <55 years– CHD in female first degree relative <65 years

• Age (men 45 years; women 55 years)† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its

presence removes one risk factor from the total count.

Other Recognized Risk Factors• Obesity: Body Mass Index (BMI)

– Weight (kg)/height (m2)– Weight (lb)/height (in2) x 703

• Obesity BMI >30 kg/m2 with overweight defined as 25-<30 kg/m 2

• Abdominal obesity involves waist circumference >40 in. in men, >35 in. in women

• Physical inactivity: most experts recommend at least 30 minutes moderate activity at least 4-5 days/week

BMI and Relative Risk of CHD Over 14 Years: Nurse’s Health Study

• Relative risk of CHD increases for BMI > 23, diabetes risk increases for BMI > 22.

• Risk also significantly increases for weight gain after age 18 years of 5 kg or more. 0

0.5

1

1.5

2

2.5

3

3.5

<21 21-22.9 23-24.9 25-28.9 >29

Diabetes as a CHD Risk Equivalent

• 10-year risk for CHD 20%• High mortality with established CHD

– High mortality with acute MI– High mortality post acute MI

Prevalence has increased over 25% in past 15 years in California, paralleling 50% increase in overweight/obesity

Probability of Death From CHD in Patients With NIDDM and in Nondiabetic Patients,

With and Without Prior MI

Kaplan-Meier estimatesHaffner SM et al. N Engl J Med 1998;339:229–234

0 1 2 3 4 5 6 7 80

20

40

60

80

100

Nondiabetic subjects without prior MI

Diabetic subjects without prior MI

Nondiabetic subjects with prior MI

Diabetic subjects with prior MI

Years

Surv

ival (%

)

General Features of the Metabolic Syndrome

• Abdominal obesity• Atherogenic dyslipidemia

– Elevated triglycerides

– Small LDL particles

– Low HDL cholesterol

• Raised blood pressure• Insulin resistance ( glucose intolerance)• Prothrombotic state• Proinflammatory state

ATP III: The Metabolic Syndrome*

*Diagnosis is established when 3 of these risk factors are present.†Abdominal obesity is more highly correlated with metabolic risk factors than is BMI. ‡Some men develop metabolic risk factors when circumference is only marginally increased.Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

<40 mg/dL<50 mg/dL

MenWomen

>102 cm (>40 in)>88 cm (>35 in)

MenWomen

110 mg/dLFasting glucose130/85 mm HgBlood pressure

HDL-C150 mg/dLTG

Abdominal obesity† (Waist circumference‡)

Defining LevelRisk Factor

© 2001, Professional Postgraduate Services®

www.lipidhealth.org

Prevalence of Selected Risk Factors in US Adults with the Metabolic Syndrome (without Diabetes)

(Wong et al., Am J Cardiol 2003, in press)

80.584.2

76.7

84.6

73.2

82.986.5

57.662.6

22.216.7

95.1

0

10

20

30

40

50

60

70

80

90

100

Men Women

Pe

rce

nt

(%)

of

Me

tab

oli

c S

yn

dro

me

Su

bje

cts

Waist Cir >40cm M/>35 cm W Blood Pressure >=130/85 or RxFasting Trig. >=150 mg/dl HDL-C <40 mg/dl M/<50 mg/dl WLDL-C >=130 mg/dl Fasting Glucose 110-125 mg/dl

Estimated Proportion of CHD Events Preventable by Control of Blood Pressure, HDL-C, LDL-C, and All 3 Factors to “Optimal”

Levels in Persons with the Metabolic Syndrome (Wong et al., Am J Cardiol, June 15, 2003)

28.2

51.2 50.646.2

38.1

80.5 82.1

45.1

0

10

20

30

40

50

60

70

80

90

Men Women

Pro

po

rtio

n o

f C

HD

Ev

en

ts P

rev

en

ted

(P

AR

%)

BP only HDL-C only LDL-C only All 3 factors

***

* p<0.05, ** p<0.01 compared to men

U.S. Department of Health and Human

Services

National Institutes of Health

National Heart, Lung, and Blood Institute

The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

The Seventh Report of the Joint National Committee onPrevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7)

National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program

National Heart, Lung, and Blood InstituteNational High Blood Pressure Education Program

Classification and Management of BP for adults

BP classificati

on

SBP* mmHg

DBP* mmHg

Lifestyle modificati

on

Initial drug therapy

Without compelling indication

With compelling indications

Normal <120 & <80 Encourage

Prehypertension

120–139 or 80–89 Yes No antihypertensive drug indicated.

Drug(s) for compelling indications. ‡

Stage 1 Hypertension

140–159 or 90–99 Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Drug(s) for the compelling indications.‡

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.


>160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

<40 40-49 50-59 60-69 70-79 80+Age (y)

17% 16% 16% 20% 20% 11%

Distribution of Hypertension Subtype in the untreated Distribution of Hypertension Subtype in the untreated Hypertensive Population in NHANES III by AgeHypertensive Population in NHANES III by Age

ISH (SBP 140 mm Hg and DBP <90 mm Hg) SDH (SBP 140 mm Hg and DBP 90 mm Hg)IDH (SBP <140 mm Hg and DBP 90 mm Hg)

0

20

40

60

80

100

Numbers at top of bars represent the overall percentage distribution of untreated hypertension by age. Franklin et al. Hypertension 2001;37: 869-874.

Frequency of hypertension

subtypes in all untreated

hypertensives (%)

BP Control RatesTrends in awareness, treatment, and control of high

blood pressure in adults ages 18–74National Health and Nutrition Examination Survey, Percent

II1976–80

II(Phase 1)1988–91

II(Phase 2)1991–94 1999–2000

Awareness 51 73 68 70

Treatment 31 55 54 59

Control 10 29 27 34

Sources: Unpublished data for 1999–2000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.

4-Year Progression To Hypertension: The Framingham Heart Study

5

18

37

0

10

20

30

40

50

Optimal Normal High-Normal

Pat

ien

ts (

%)

(<120/80 mm Hg)

(130/85 mm Hg) (130-139/85-89 mm

Hg)Vasan, et al. Lancet 2001;358:1682-86

Participants age 36 and older

SBP-Associated Risks: MRFIT

Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.

SBP versus DBP in Risk of CHD Mortality

Diastolic BP(mm Hg)

Systolic BP(mm Hg)

CHD Death Rate

100+90–99

80–8975–79

70–74<70 <120

120–139

140–159

160+

48.3

20.6

10.311.8

8.88.5

9.2

23.8

16.9

13.912.8

12.611.8

31.0

25.524.6 25.3

25.224.9

37.434.7

43.8

38.1

80.6

Lifestyle ModificationModification Approximate SBP reduction

(range)

Weight reduction 5–20 mmHg/10 kg weight loss

Adopt DASH eating plan

8–14 mmHg

Dietary sodium reduction 2–8 mmHg

Physical activity 4–9 mmHg

Moderation of alcohol consumption

2–4 mmHg

Classification and Management of BP for adults

BP classification

SBP* mmHg

DBP* mmHg

Lifestyle modificati

on

Initial drug therapy

Without compelling indication

With compelling indications

Normal <120 &

<80 Encourage

Prehypertension

120–139

or 80–89

Yes No antihypertensive drug indicated.

Drug(s) for compelling indications. ‡


140–159

or 90–99

Yes Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combination.

Drug(s) for the compelling indications.‡

Other antihypertensive drugs (diuretics, ACEI, ARB, BB, CCB) as needed.


>160 or >100 Yes Two-drug combination for most† (usually thiazide-type diuretic and ACEI or ARB or BB or CCB).

*Treatment determined by highest BP category.†Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.‡Treat patients with chronic kidney disease or diabetes to BP goal of <130/80 mmHg.

Total Cholesterol Distribution: CHD vs Non-CHD Population

Castelli WP. Atherosclerosis. 1996;124(suppl):S1-S9.1996 Reprinted with permission from Elsevier Science.

35% of CHD 35% of CHD Occurs in Occurs in People with People with TC<200 mg/dLTC<200 mg/dL

150 200

Total Cholesterol (mg/dL)

250 300

No CHD

CHD

Framingham Heart Study—26-Year Follow-up

Low HDL-C Levels Increase CHD Risk Even When Total-C Is Normal (Framingham)

Risk of CHD by HDL-C and Total-C levels; aged 48–83 yCastelli WP et al. JAMA 1986;256:2835–2838

02468

101214

< 40 40–49 50–59 60< 200

230–259200–229

260

HDL-C (mg/dL) Tota

l-C (m

g/dL

)

14

-y in

cid

en

ce

rate

s (%

) fo

r C

HD

11.24

11.91

12.50

11.91

6.56

4.67

9.05

5.53

4.85

4.153.77

2.782.06

3.83

10.7

6.6

-30-33

-29 -28-22

-40

-30

-20

-10

0LDL-C Stroke

Totalmortality

%

**

† ‡

§

*Confidence interval (CI) not reported.†95% CI, 14%-41%.‡95% CI, 16%-37%.§95% CI, 12%-31%.Hebert PR et al. JAMA. 1997;278:313-321.

Impact of Lowering LDL-C on CVD Events and Total Mortality

Nonfatal/fatal CHD

CVDmortality

Risk Factors

• Major risk factors account for only about half of the variability in CHD risk in the US population

• Emerging risk factors could enhance predictive power in individuals– Lipid– Nonlipid

NCEP ATP III. Circulation. 2002;106:3145-3421.

Risk Factors for Future Cardiovascular Events: WHS

Relative Risk of Future Cardiovascular Events0

Ridker PM et al. N Engl J Med 2000;342:836-843.

Lipoprotein(a)

Homocysteine

IL-6

TC

LDL-C

sICAM-1

SAA

Apo B

TC:HDL-C

hs-CRP

hs-CRP + TC:HDL-C1.0 2.0 4.0 6.0

Quartile of TC: Quartile of TC:

HDL-CHDL-C

Quartile Quartile of hs-CRP of hs-CRP

43

21 1

23

4

9

8

7

6

5

4

3

2

1

0

hs-CRP, Lipids, and Risk of Future Coronary Events: Women's Health Study (WHS)

Ridker PM et al. N Engl J Med 2000;342:836-843.

ATP III: Assessment of Risk

For persons without known CHD, other forms of

atherosclerotic disease, or diabetes:

• Count the number of risk factors.

• Use Framingham scoring for persons with 2 risk factors* to determine the absolute 10-year CHD risk.

*For persons with 0–1 risk factor, Framingham calculations are not necessary.

Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497. © 2001, Professional Postgraduate Services®

www.lipidhealth.org

Note: Risk estimates were derived from the experience of the Framingham Heart Study, a predominantly Caucasian population in Massachusetts, USA.

Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

Assessing CHD Risk in MenStep 1: Age

YearsPoints

20-34 -935-39 -440-44 045-49 350-54 655-59 860-64 1065-69 1170-74 1275-79 13

Step 2: Total Cholesterol

TC Points at Points at Points at Points atPoints at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 <160 0 0 0 0

0160-199 4 3 2 1

0200-239 7 5 3 1

0240-279 9 6 4 2

1280 11 8 5 3

1

HDL-C(mg/dL) Points

60 -1

50-59 0

40-49 1

<40 2

Step 3: HDL-Cholesterol

Systolic BP PointsPoints

(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

Step 4: Systolic Blood Pressure

Step 5: Smoking Status

Points at Points at Points at Points atPoints at

Age 20-39 Age 40-49 Age 50-59 Age 60-69Age 70-79

Nonsmoker 0 0 0 00

Smoker 8 5 3 11

Age

Total cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total

Step 6: Adding Up the Points

Point Total 10-Year Risk Point Total 10-Year Risk

<0 <1% 118%

0 1% 1210%

1 1% 1312%

2 1% 1416%

3 1% 1520%

4 1% 1625%

5 2% 1730%

6 2%7 3%8 4%9 5%

10 6%

Step 7: CHD Risk

ATP III Framingham Risk Scoring


www.lipidhealth.org

Men

YearsPoints20-34 -935-39 -440-44045-49350-54655-59860-641065-691170-741275-7913

Step 1: Age

Expert Panel on Detection, Evaluation, and Treatment of High BloodCholesterol in Adults. JAMA. 2001;285:2486-2497.

Women

YearsPoints20-34 -735-39 -340-44 045-49 350-54 655-59 860-641065-691270-741475-7916



www.lipidhealth.org

Step 2: Total Cholesterol

Note: TC and HDL-C values should be the average of at least two fasting lipoprotein measurements.


MenTC Points at Points at Points at Points at

Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age

70-79 <160 0 0 0 0

0160-199 4 3 2 1

0200-239 7 5 3 1

0240-279 9 6 4 2

1280 11 8 5 3

1

WomenTC Points at Points at Points at Points at

Points at(mg/dL) Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age

70-79 <160 0 0 0 0

0160-199 4 3 2 1

1200-239 8 6 4 2

1240-279 11 8 5 3

2280 13 10 7 4

2



www.lipidhealth.org

Step 3: HDL-Cholesterol

Note: HDL-C and TC values should be the average of at least two fasting lipoprotein measurements.


Men

HDL-C(mg/dL)

Points60 -1

50-59 0

40-49 1

<40 2

Women

HDL-C(mg/dL)

Points60 -1

50-59 0

40-49 1

<40 2



www.lipidhealth.org

Step 4: Systolic Blood PressureMen

Systolic BP Points Points(mm Hg) if Untreated if Treated

<120 0 0120-129 0 1130-139 1 2140-159 1 2160 2 3

Note: The average of several BP measurements is needed for an accuratemeasurement of baseline BP. If an individual is on antihypertensive treatment,extra points are added.


WomenSystolic BP Points

Points(mm Hg) if Untreated if

Treated <120 0 0

120-129 1 3130-139 2 4140-159 3 5160 4 6



www.lipidhealth.org

Step 5: Smoking Status

Note: Any cigarette smoking in the past month.


Men Points at Points at Points at Points at

Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69 Age

70-79 Nonsmoker 0 0 0 00

Smoker 8 5 3 1 1

Women Points at Points at Points at Points at

Points at Age 20-39 Age 40-49 Age 50-59 Age 60-69

Age 70-79 Nonsmoker 0 0 0 00

Smoker 9 7 4 2 1



www.lipidhealth.org

Step 6: Adding Up the Points(Sum From Steps 1–5)


AgeTotal cholesterol

HDL-cholesterol

Systolic blood pressure

Smoking status

Point total



www.lipidhealth.org

Step 7: CHD Risk for Men

Note: Determine the 10-year absolute risk for hard CHD (MI and coronary death) from point total.


Point Total 10-Year Risk Point Total 10-Year Risk

<0 <1% 118%

0 1% 1210%

1 1% 1312%

2 1% 1416%

3 1% 1520%

4 1% 1625%

5 2% 1730%

6 2%7 3%8 4%9 5%10 6%



www.lipidhealth.org

CHD Risk Equivalents• > 20% 10-year risk of CHD

(Framingham projections) (downloadable risk algorithms at www.nhlbi.nih.gov)

• Diabetes

• Other forms of clinical atherosclerotic disease

– Peripheral arterial disease

– Abdominal aortic aneurysm

– Carotid artery disease

NCEP ATP III. JAMA. 2001;285:2486-2497.

ACC 34th Bethesda Conference Task Force 4: How do We Select Patients for Atherosclerosis Imaging?

• The ability to select higher risk asymptomatic subsets from the population that would benefit from an earlier or more aggressive risk factor intervention is a key advantage of subclinical disease screening

• Persons with diabetes are considered CHD risk equivalents already warranting aggressive treatment as such; screening for atherosclerosis is not needed

Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)

• Patients at intermediate risk for total CHD comprise about 40% of the adult population.

• They have at least 1 major risk CHD factor and have a 6-20% 10-year risk of a hard CHD event, possibly warranting further risk stratification by noninvasive tests to assess atherosclerotic burden.

Wilson, Smith, Blumenthal, Wong, 34th Bethesda Conference Task Force 4, J Am Coll Cardiol 2003 (in press)

Significant Coronary Artery Calcium (Score >400)

ATP III: Nutritional Components of the TLC Diet

Expert Panel on Detection, Evaluation, and Treatment ofHigh Blood Cholesterol in Adults. JAMA. 2001;285:2486-2497.

*Trans fatty acids also raise LDL-C and should be kept at a low intake.Note: Regarding total calories, balance energy intake and expenditure tomaintain desirable body weight.

<200 mg/dCholesterol

~15% of total caloriesProtein

20–30 g/dFiber

50%–60% of total caloriesCarbohydrate (esp. complex carbs)

25%–35% of total caloriesTotal fat

Up to 20% of total caloriesMonounsaturated fat

Up to 10% of total caloriesPolyunsaturated fat

<7% of total caloriesSaturated fat*

Recommended IntakeNutrient


www.lipidhealth.org

Possible Benefits From Other Therapies

Therapy Result

• Soluble fiber in diet (2–8 g/d) (oat bran, fruit, and vegetables)

• Soy protein (20–30 g/d)

• Stanol esters (1.5–4 g/d) (inhibit cholesterol absorption)

• Fish oils (3–9 g/d) (n-3 fatty acids)

LDL-C 1% to 10%

LDL-C 5% to 7%

LDL-C 10% to 15%

Triglycerides 25% to 35%

Jones PJ. Curr Atheroscler Rep. 1999;1:230-235.Lichtenstein AH. Curr Atheroscler Rep. 1999;1:210-214.Rambjor GS et al. Lipids. 1996;31:S45-S49.Ripsin CM et al. JAMA. 1992;267:3317-3325.

Dietary Approaches to Stop Hypertension (DASH)

• Diet high in fruits and vegetables and low-fat dairy products lowers blood pressure (11 mmHg SBP/ 5 mmHg DBP lower than traditional US diet), including more than a sodium-restricted diet

• Recommends 7-8 servings/day of grain/grain products, 4-5 vegetable, 4-5 fruit, 2-3 low- or non-fat dairy products, 2 or less meat, poultry, and fish.

• NEJM 1997; 366: 1117-24.

AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update – Risk

Assessment

Circulation 2002; 106: 388-391 • Beginning age 20:

– Regularly assess family history, smoking status, diet, alcohol intake, and physical activity

– BP, BMI, waist circumference, pulse assessed at last every 2 years; fasting lipid profile and glucose measured every 5 years (2 yrs if other risk factors present.

Beginning age 40:Assess 10-year risk of CHD using a multiple risk factor score (start younger if 2+ risk factors present); those at greater than 20% risk considered CHD risk equivalent

AHA Guidelines for Primary Prevention of CVD and Stroke: 2002 Update (cont.)– Risk

Intervention• Smoking – complete cessation and no exposure to

environmental tobacco smoke • BP control - <140/90 (<130/85 if renal insufficiency or CHF,

<130/80 for diabetes)• Dietary intake - <10% calories from saturated fat, <300 mg/d

cholesterol, <6g/d salt, limit alcohol to 2 drinks/d in men or 1 drink/d women if drinking

• Aspirin – consider 75-160 mg/d for those at 10-y risk of 10% or greater

• Lipids – goals per NCEP guidelines• Physical activity – At least 30 minutes/d on most or all days of

week• Weight management – Achieve desirable BMI 18.5-<25, waist

cir <=40 in men and <=35 in women• Diabetes management – Goal fasting glucose <110 mg/dl and

HgbA1c <7%

Considerations for Secondary Prevention

• CVD event rates in those with pre-existing disease are 5-7 times greater than healthy individuals.

• Diabetics run a similar event rate as those with a previous myocardial infarction (Haffner)

• Risk factor modification is the cornerstone of secondary prevention efforts

• Categories of patients for secondary prevention efforts: 1) stable CHD, 2) unstable angina, 3) prior MI, 4) prior CABG, and 5) prior PTCA

Get with the Guidelines-CVD and Stroke

AHA / ASA’s Program for Saving Lives Through Effective Implementation of Secondary

Prevention Guidelines

Adapted from Smith, Circulation 2001Adapted from Smith, Circulation 2001

AHA GuidelinesAHA Guidelines• Cessation of smoking• Lipid Management Goals• Physical activity• Weight management• Antiplatelet/anticoagulants• ACE inhibitors• Beta blockers • Blood pressure control

• Early Aspirin• Early Beta-Blockers• Reperfusion for AMI

• Stroke: Atrial Fibrillation and Alcohol Use

Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III2001Adapted from the AHA/ACC Guidelines 2001 and NCEP-ATP III2001

Comprehensive Medical Therapy For Patients with CHD or Other

Atherosclerotic Vascular Disease Risk Reduction

• ASA 20-30%• Beta Blockers 20-35%• ACE inhibitors 22-25%• Statins 25-42%

– LDL Target < 100 mg/dl

• Smoking Cessation 50%

Implement Guidelines HERE

HealthyPopulation

Undiagnosedor Untreated

In Treatment

AcuteEvent

PostEvent

Implementation Statistics

Indicator Rate Optimal

ASA 85%* 100%

Beta Blocker 72%* 100%

ACE-I 71%* 100%

Smoking Cessation 40%* 100%

Lipid Lowering 37%** 96%

*HCFA, 1998 **NRMI 2nd Q 2000

Improvement in Treatment Utilization is Associated With A Marked Reduction in

Clinical Events

14.8%

6.4%

0

5

10

15

20

Pre-CHAMP Post-CHAMP

Death or Recurrent MI%RR0.43p<0.01

256 AMI pts discharged in92/93 Pre-CHAMP- compared to 302 pts in 94/95 Post-CHAMPASA 78% vs 92%; BetaBlocker12% vs 61%; ACEI 4% vs 56%; Statin 6%vs 86%

Fonarow ,American Journal of Cardiology 2001(in press)

CAD Treatment Gap - Community95

18

0102030405060708090

100

Physician Awareness of NCEPGuideline

Patient Treated to Goal

Provider awareness does not equal successful implementation

Pearson Arch Intern Med 2000;160:459-67

• Systems to Translate Efficacy Effectiveness

SYSTEMS• Outcomes associated

with an intervention under ideal circumstances– Clinical trial

reported in literature

– Benchmarking

EFFICACY EFFECTIVENESS

• Outcomes associated with an intervention in the real world – Hospital– Outpatient– Across

Continuum

Bridging the Gap Between Efficacy and Effectiveness

We are in a new business, from development of

guidelines to implementation of guidelines

Assess CHD Treatment RatesAnalyze

Discharge Rates

Evaluate AssessmentGWTG Team Reviews

Summary Reports

Refine ProtocolGWTG Team Identifies Areas for Improvement

Implement Refined ProtocolGWTG Team Coordinates Implementation of Refined

Protocol

Find & Support a Find & Support a ChampionChampion

Building the Hospital Team

• Physicians• Nurses• Pharmacists • Hospital Administrators• Directors of Quality

Improvement and Case Management

• Cardiac Rehab Team

It’s never too early to Get With The Guidelines!

If Get With The

Guidelines is

implemented,

more than 40,000+

lives could be saved

every year!

The UCI Heart Disease Prevention Program

see us at: www.heart.uci.edu

cardiovascular risk factor overview and management

Documents

metabolic risk factors

chd risk factor

diabetes risk

chd risk equivalent

year risk

high cholesterol

prior mi nondiabetic

major risk factors cigarette