Routine screening for CYP2C19 polymorphisms for patients being treated with clopidogrel is not recommended.

Recent efforts directed at potential litigation in Hawai'i have resulted in a renewed interest for genetic screening for cytochrome P450 2C19 (CYP2C19) polymorphisms in patients treated with clopidogrel. Clopidogrel is an antiplatelet agent, frequently used in combination with aspirin, for the prevention of thrombotic complications with acute coronary syndrome and in patients undergoing percutaneous coronary interventions. Cytochrome P-450 (CYP) 2C19 is an enzyme involved in the bioactivation of clopidogrel from a pro-drug to an active inhibitor of platelet action. Patients of Asian and Pacific Island background have been reported to have an increase in CYP2C19 polymorphisms associated with loss-of-function of this enzyme when compared to other ethnicities. This has created an interest in genetic testing for CYP2C19 polymorphisms in Hawai'i. Based upon our review of the current literature, we do not feel that there is support for the routine screening for CYP2C19 polymorphisms in patients being treated with clopidogrel; furthermore, the results of genetic testing may not be helpful in guiding therapeutic decisions. We recommend that decisions on the type of antiplatelet treatment be made based upon clinical evidence of potential differential outcomes associated with the use of these agents rather than on the basis of genetic testing.

Closing the gap "Disparity in Native Hawaiian cardiac care".

PURPOSE: Queen's Heart, the cardiac service line at the Queen's Medical Center (QMC), Honolulu, Hawaii, recognizes the importance of closing the health disparity gap that affects the Native Hawaiian population. The purpose of this study was to examine the process and outcomes of health care among Native Hawaiians with heart disease, and to evaluate the impact of a multidisciplinary, culturally sensitive effort to improve quality of care. An inpatient program was created by assembling a team of practitioners who have an affinity for Native Hawaiian culture to address the health care of the Native Hawaiian people. METHODS: All Native Hawaiian patients who were admitted to The Queen's Medical Center from January 2007 to December 2008 became participants of the program. Baseline outcomes data for cardiac core measures, length of stay, 30 day readmission rates, and adverse events were reviewed by the team before the study was initiated. Educational materials were developed to provide culturally specific disease management information to patients and family members. The patient educators and discharge counselors provided patients with the education and tools they needed to engage in self care management. Heart failure disease management ensured that all Native Hawaiian patients receive appropriate quality care, individualized heart failure education, and a definitive plan for out patient follow up. The Integrative Care Program provided a holistic perspective of healing. RESULTS: All quality indicators for Native Hawaiian patients with cardiac disease have improved. Patient satisfaction rates have remained at the 99th percentile. There has been a marked improvement in adverse events following percutaneous coronary interventions (PCI) for Native Hawaiian patients. Readmissions that occurred in less than 30 days for patients admitted with myocardial infarctions and heart failure have improved and are now essentially the same as all other patient populations. CONCLUSIONS: Culturally sensitive and patient centered care, delivered by the team of specialists from Queen's Heart, has allowed patients to incorporate cultural preferences into their care and recovery. Readmission rates have decreased, mortality rates have improved, and patient and family satisfaction is enhanced.