Optimizing management of patients with coronary artery disease: how do we get there?

Debabrata Mukherjee1,*

Gill Heart Institute, Division of Cardiovascular Medicine, University of Kentucky, 900 S. Limestone Street, 326 Wethington Building, Lexington, KY 40536-0200, USA

* Corresponding author. Tel: +1 859 323 5630; fax: +1 859 323 6475. E-mail address: mukherjee@uky.edu

This editorial refers to ‘Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization’{dagger} by M.J. Lenzen et al., on page 1169

Cardiovascular disease remains the leading cause of morbidity and mortality globally.1 Despite marked advances in the fields of mechanical and pharmacological therapies for coronary artery disease there continues to remain large gaps in the utilization of these effective therapies. Over the last decade, several pharmacological therapies have been shown to be very effective in reducing morbidity and mortality in patients with cardiovascular diseases. These agents, including antiplatelet agents, statins, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers, although individually very effective in reducing secondary cardiovascular events are even more effective when used in combination and may have2 incremental benefits in patients with acute coronary syndrome (Figure 1) and in those undergoing vascular interventions.3 However, despite strong and unequivocal benefits of these agents, these effective secondary preventive therapies continue to be underutilized.4



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Figure 1 Effect of combined use of evidence-based medical therapies on 6 month mortality in patients with acute coronary syndromes. Composite appropriateness levels (I–IV) are compared with level 0 (non use of any of the indicated medications) and shows a gradient of survival benefit in this cohort with use of higher number of evidence-based medications. Evidence-based therapies for this analysis included anti-platelet agents, beta-blockers, ACE-inhibitors, and lipid-lowering therapy. (Adapted with permission from Mukherjee et al.2)

 
Lenzen et al.5 describe the results of the Euro Heart Survey programme. The Euro Heart Survey on coronary revascularization was conducted in 130 voluntary participating hospitals from 31 ESC member countries with the objective to evaluate clinical practice, adherence to Guidelines, differences in the management and outcome of patients, and to assess to what extent the patients of daily practice are represented in randomized clinical trials. The participating centres were asked to enroll blocks of 40 consecutive patients. The present report discusses consecutive patients undergoing invasive diagnostic or therapeutic catheterization, of which patients with >50% diameter stenoses in at least one major epicardial vessel were asked to participate.5 The authors report several important findings. They report appropriate use of mechanical revascularization in the management of these patients, but considerable deficiencies in the use of GP IIb/IIIa receptor blockers and underuse of ACE-inhibitors and statins. Moreover, post-procedural necrosis markers were measured in only 61% of all percutaneous coronary intervention (PCI) procedures and in one-third of patients undergoing coronary artery bypass surgery (CABG). This is despite evidence that levels of cardiac enzymes after either CABG or PCI are an independent predictor of cardiac mortality and subsequent myocardial infarction and other major adverse events.6

The article by Lenzen et al.5 provides important baseline information on management of patients with coronary artery disease throughout Europe and demonstrate that expensive procedures, such as mechanical revascularization, may be more easily embraced by practicing clinician, because they may translate into higher revenues for institutions and physicians. The report also highlights major deficiencies in utilization of effective pharmacotherapies for these patients. The logical question that arises from the findings of this report is how then can we improve quality of care in patients with coronary artery disease and narrow the existing gap in utilization of effective therapies?

A limitation of this survey was a lack of feedback to participating hospitals and physicians regarding their quality of care and lack of insight regarding significant heterogeneity in practice patterns among the participating hospitals. We have learnt that quality improvement exercises, which promote use of systems that embed guideline knowledge into the care process itself and provide feedback to physicians, are relatively more successful.7 In one such improvement initiative, the Guidelines Applied in Practice (GAP) project in the state of Michigan, one physician and one nurse leader from outside the hospital system from the Southeast Michigan Quality Forum were assigned to serve as leaders.8 They assisted in the development of quality improvement plans, tool kit customization, and project implementation. The project demonstrated quality improvement among a variety of institutions, patients, and caregivers.8 An important component of the GAP tools included providing patients with education and empowerment and to help them better understand their disease and the long-term goals of its treatment, including lifestyle strategies. There was also an emphasis on standard orders and discharge tools which reminded caregivers to consider evidence-based therapies in every patient and on creation of a system which includes patients, nurses, and physicians in a review of care priorities and provide continuous feedback to them promote improvement in quality of care.

Any intervention aiming to modify physician behaviour must be effective to support the adoption of changes into clinical practice.7 A systematic approach, particularly targeting use of quality improvement tools, involving both caregivers and patients, and targeting reimbursement to appropriate therapy is more likely to be successful in improving adherence to guidelines and performance measures.7,8

The appropriate use of evidence-based therapy has significant health outcome and policy implications. Peterson et al.9 demonstrated that in-hospital myocardial infarction mortality rates are 40% lower at hospitals that adhere to published guidelines than they are at those that inconsistently or rarely provide recommended therapy. In the future, substantial global funding and support for quality measurement and improvement initiatives will be needed to implement the accumulating evidence of effective medical therapies into routine clinical practice and translate efficacy into effectiveness.10 Patients with established coronary artery disease reperesent an important cohort in which secondary vascular disease prevention is likely to be particularly useful and cost-effective. Cardiovascular specialists have an opportunity not only to provide high-quality and appropriate coronary interventions, but also to seize the peri-procedural moment in aggressively treating the underlying atherosclerotic process through lifestyle modifications and effective pharmacological therapies. The attention to these disease management opportunities is more likely to affect both quality and quantity of life rather than the revascularization procedure itself.

Footnotes

The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology. Back

{dagger} doi:10.1093/eurheartj/ehi238 Back

References

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  2. Mukherjee D, Fang J, Chetcuti S, Moscucci M, Kline-Rogers E, Eagle KA. Impact of combination evidence-based medical therapy on mortality in patients with acute coronary syndromes. Circulation 2004;109:745–749.[Abstract/Free Full Text]
  3. Mukherjee D, Lingam P, Chetcuti S, Grossman PM, Moscucci M, Luciano AE, Eagle KA. Missed opportunities to treat atherosclerosis in patients undergoing peripheral vascular interventions: insights from the University of Michigan Peripheral Vascular Disease Quality Improvement Initiative (PVD-QI2). Circulation 2002;106:1909–1912.[CrossRef][ISI][Medline]
  4. Vogel RA. Risk factor intervention and coronary artery disease: clinical strategies. Coron Artery Dis 1995;6:466–471.
  5. Lenzen M, Boersma E, Bertrand ME, Maier W, Moris C, Piscione F, Sechtem U, Stahle E, Widimsky P, de Jaegere P, Scholte op Reimer WJM, Mercado N, Wijns W. Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization. Eur Heart J 2005;26:1169–1179. First published on March 31, 2005, doi:10.1093/eurheartj/ehi238.[Abstract/Free Full Text]
  6. Mukherjee D, Oz M, Prager R, Eagle KA. Elective coronary revascularization, an iatrogenic form of acute coronary syndrome: how can clinicians reduce the risks? Am Heart J 2004;148:371–377.[CrossRef][ISI][Medline]
  7. Mukherjee D, Eagle KA. Improving quality of care in the real world: efficacy versus effectiveness? Am Heart J 2003;146:946–947.[CrossRef][ISI][Medline]
  8. Mehta RH, Montoye CK, Gallogly M, Baker P, Blount A, Faul J. Improving quality of care for acute myocardial infarction: The Guidelines Applied in Practice (GAP) Initiative. JAMA 2002; 2871269–1276.[Abstract/Free Full Text]
  9. Peterson E, Parsons L, Pollack C, Newby LK. Variation in AMI care quality across 1,085 US hospitals and its association with hospital mortality rates. Circulation 2002;106:II722.
  10. Spertus JA, Radford MJ, Every NR, Ellerbeck EF, Peterson ED, Krumholz HM. Challenges and opportunities in quantifying the quality of care for acute myocardial infarction: summary from the Acute Myocardial Infarction Working Group of the American Heart Association/American College of Cardiology First Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. J Am Coll Cardiol 2003;41:1653–1663.[CrossRef][Medline]

Related articles in EHJ:

Management and outcome of patients with established coronary artery disease: the Euro Heart Survey on coronary revascularization
M.J. Lenzen, E. Boersma, M.E. Bertrand, W. Maier, C. Moris, F. Piscione, U. Sechtem, E. Stahle, P. Widimsky, P. de Jaegere, W.J.M. Scholte op Reimer, N. Mercado, and W. Wijns
EHJ 2005 26: 1169-1179. [Abstract] [Full Text]  




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