Evaluation of a postdischarge coronary artery disease management program.

OBJECTIVES: We conducted a demonstration project to assess the value of a nurse practitioner (NP) based coronary artery disease management (CAD-DM) program for patients with an acute coronary syndrome (ACS) or percutaneous coronary intervention. METHODS: Patients were recruited to attend three 1-h monthly visits. The intervention included assessment of clinical symptoms and guideline-based treatments; education regarding CAD/ACS; review of nutrition, exercise, and appropriate referrals; and recognition of significant symptoms and emergency response. RESULTS: Two hundred thirteen (84.5%) completed the program. Physician approval for patient participation was 99%. Average age was 63 ± 11 years, 70% were male, and 89% white. At baseline, 61% (n = 133) had one or more cardiopulmonary symptoms, which declined to 30% at 12 weeks, p < .001. Sixty-nine percent attended cardiac rehabilitation or an exercise consult. Compared to the initial assessment, an additional 20% were at low-density lipoprotein cholesterol < 70 mg/dL (p = .04), an additional 35% met exercise goals (p < .0001), and there was an improvement in the mental (baseline 49.7 vs. 12 weeks 53, p = .0015) and physical components (44 vs. 48, p = .002) of the SF-12 health survey. CONCLUSION: This NP-based CAD-DM program was well received and participants demonstrated improvement in physical and mental health, and increased compliance with recommended lifestyle changes.

Lipoprotein (a): perspectives from a lipid-referral program.

BACKGROUND: Lipoprotein (a) [Lp(a)] has a strong association with coronary disease (CHD). We evaluated the implications of implementing a niacin strategy in persons above low risk by the Framingham risk score (FRS). METHODS: Patients referred to a university lipid management program from January 2004 to June 2010 had an Lp(a) level measured at initial evaluation. Factors associated with an increase in Lp(a) and predictors of a high risk Lp(a) (≥50 mg/dL) were assessed. FRS and Lp(a) levels were used to assess eligibility for niacin with an Lp(a) ≥50 mg/dL. RESULTS: A total of 692 patients (57% male, mean age 52 ± 14 years) had a mean Lp(a) of 32 ± 40 mg/dL. In a multiple logistic regression model, African-American race, female gender, presence of CHD, and lower triglyceride levels were significant predictors of high risk Lp(a). Ten percent were determined to be intermediate and 44% high risk by FRS. A total of 9% of intermediate- and 26% of high-risk patients had an Lp(a) ≥50 mg/dL, and 84% were not taking niacin. A total of 19% of moderate- and high-risk patients were eligible for initiation of niacin based upon values ≥50 mg/dL. If niacin were also used for an high-density lipoprotein cholesterol levels ≤40 mg/dL, only 5.1% additional patients would require niacin. CONCLUSION: High-risk levels of Lp(a) are associated with female gender, African- American race, and CHD. 19% of moderate and high risk patients would be candidates for treatment with niacin if the indication is a cutpoint Lp(a) ≥50 mg/dL.

Effect of use of combination evidence-based medical therapy after acute coronary syndromes on long-term outcomes.

Several medications have individually been shown to reduce mortality in patients with acute coronary syndromes (ACS), but data on long-term outcomes related to the use of combinations of these medications are limited. For 2,684 consecutive patients admitted with ACS from January 1999 and January 2007, a composite score was calculated correlating with the use upon discharge of indicated evidence-based medications (EBMs): aspirin, ß blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and lipid-lowering agents. Multivariate models were used to examine the impact of EBM score on 2-year events with adjustment for components of the Global Registry of Acute Coronary Events (GRACE) risk score, thienopyridine use, and year of discharge. Women were older, had more co-morbidities, and were less likely to receive all 4 EBMs (53% vs 64%, p < 0.0001) than men. Patients who received all 4 indicated EBMs had a significant 2-year survival benefit compared to patients who received ≤1 EBM (odds ratio 0.25, 95% confidence interval 0.15 to 0.41), which was observed when men and women were examined separately (for men, odds ratio 0.22, 95% confidence interval 0.11 to 0.44; for women, odds ratio 0.3, 95% confidence interval 0.15 to 0.63). A modest benefit, in terms of cardiovascular disease events (myocardial infarction, rehospitalization, stroke, and death), was observed only for men who received all 4 EBMs. In conclusion, a combination of cardiac medications at the time of ACS discharge is strongly associated with 2-year survival in men and women, suggesting that discharge is an important time to prescribe secondary preventative medications.

Does the outcome justify an oral-first treatment strategy for management of pulmonary arterial hypertension?

BACKGROUND: Guidelines for the treatment of World Health Organization (WHO) functional class (FC) III pulmonary arterial hypertension (PAH) provide for oral (PO) therapy or parenteral prostacyclins at the discretion of expert physicians. The objective of this study was to assess the appropriateness of PO-first treatment in patients with WHO FC III PAH. METHODS: This study was a retrospective analysis of 79 treatment-naive adult patients with idiopathic, familial, or anorexigen-associated PAH, referred to a single pulmonary hypertension center. Forty-eight received either PO therapy with an endothelin receptor antagonist, calcium channel blocker, or phosphodiesterase inhibitor (PO group) and 31 an IV or subcutaneous (SC) prostacyclin (IV/SC group). RESULTS: Patients in the IV/SC group had a significantly worse baseline hemodynamic profile; however, on univariate analysis, there was no association between hemodynamics and mortality. Initial treatment with PO vs IV/SC therapy was associated with a lower overall mortality (20.8% vs 45.2%, P = .02) and a lower 5-year mortality (14.6% vs 32.3%, P = .062). Based on the National Institutes of Health equation, actual survival for patients who received PO therapy was greater than predicted at 5 years. Finally, there were similar improvements between groups in 6-min walk distance (P = .38) at 6 to 12 months after initiation of treatment. CONCLUSIONS: For WHO FC III PAH that is idiopathic, familial, or anorexigen associated, the clinical decision for treatment with a PO-first strategy is associated with a high survival rate when patients are appropriately risk stratified prior to initiation of therapy. The more potent prostacyclins can be reserved for high-risk patients, those with evidence of disease progression, or those with treatment failure.

Potential effects on clinical management of treatment algorithms on the basis of apolipoprotein-B/A-1 and total/high-density lipoprotein-cholesterol ratios.

BACKGROUND: Apolipoprotein-B/A-1 (apoB/A-R) and total/high-density lipoprotein-cholesterol ratios (TC/HDL-R) outperform non-high-density lipoprotein-cholesterol (non-HDL-C) suggested by Adult Treatment Panel (ATP) III guidelines for predicting cardiovascular (CV) outcomes. OBJECTIVE: To evaluate the potential effects that implementing our proposed apoB/A-R and TC/HDL-R treatment algorithms would have on clinical management. METHODS: We performed a chart review of all patients referred to the University of Michigan Lipid Clinic from January 2004 to June 2010. ATP III guidelines, including Framingham Risk Scores, were used to determine whether patients met non-HDL-C goals upon referral. Next, we evaluated whether subsequent management would differ if algorithms based upon potential apoB/A-R or TC/HDL-R targets derived from the literature were followed. RESULTS: Among patients (n = 692), mean non-HDL-C, apoB/A-R, and TC/HDL-R were 192.2 ± 85.8 mg/dL, 0.92 ± 0.64, and 6.7 ± 8.0, respectively. Although moderately well correlated with apoB (r = 0.56, P < .01), non-HDL-C was less related to apoB/A-R (r = 0.20, P < .01) and TC/HDL-R (r = 0.39, P < .01). Most low-risk patients (<2 risk factors; n = 207) at non-HDL-C goal (<190 mg/dL) also met apoB/A-R <0.9 (79%) and TC/HDL-R <6.0 (92%) targets. However, a minority of high-risk patients (Framingham Risk Score >20%, cardiovascular disease or risk equivalent; n = 307) meeting non-HDL-C goal (<130 mg/dL) achieved targets for apoB/A-R <0.5 (21%) or TC/HDL-C <3.5 (42%). The percentages of intermediate-risk patients meeting both non-HDL-C and ratio goals varied; nonetheless, few met an aggressive apoB/A-R <0.6 (36%-50%) target. CONCLUSIONS: Most high- and many intermediate-risk patients at non-HDL-C goals would require more aggressive treatment to reach the suggested apoB/A-R or TC/HDL-R targets. Whether this strategy yields superior outcomes merits future investigation.

Psychological distress in cardiac rehabilitation participants.

PURPOSE: Limited data are available on the psychosocial characteristics of patients entering cardiac rehabilitation (CR). We characterized the psychological and clinical profiles of men and women entering CR to determine which, if any, characteristic identifies persons at high risk for psychological distress. METHODS: The records of 417 patients enrolled in phase II CR between January 2001 and December 2004 were analyzed. One hundred forty-eight of these patients underwent a comprehensive Symptom Checklist-90 psychological survey. The analysis focused on measures of depression, anxiety, hostility, somatization, and a global severity index. RESULTS: Mean age of the patients was 60.6 years and 20.9% of them were women. More than one-third had a score of 90th percentile or more in at least 1 psychological category, and 23% had a score of 90th percentile or more in 3 or more categories. Approximately 20% and 36% of patients scoring in the 90th percentile or more and 98th percentile or more of depressive symptoms, respectively, had a history of depression. There was no difference in Symptom Checklist-90 scores by gender, age, education, work status, type of coronary event, metabolic syndrome, tobacco use, cerebrovascular disease, peripheral vascular disease, or diabetes. There was no relationship between psychological symptoms and indication for CR, although a trend of more somatic symptoms was seen in those who underwent an acute coronary syndrome and did not receive revascularization. CONCLUSION: Considering the prevalence of psychological distress in CR patients and the lack of clinical identifiers, routine assessment could help identify those who are at increased risk of noncompliance and may benefit from psychological and/or pharmacological intervention.

Patient-related diet and exercise counseling: do providers' own lifestyle habits matter?

The goal of this research was to evaluate the personal health behaviors of physicians in training and attending physicians in association with patient-related lifestyle counseling. Physicians at a major teaching hospital were surveyed regarding their personal lifestyle behavior, perceived confidence, and frequency of counseling patients regarding lifestyle behaviors. One hundred eighty-three total responses were received. Trainees were more likely to consume fast food and less likely to consume fruits and vegetables than attendings. Attending physicians were more likely to exercise 4 or more days per week and more than 150 minutes per week. Attending physicians were more likely to counsel their patients regarding a healthy diet (70.7% vs 36.3%, P<.0001) and regular exercise (69.1% vs 38.2%, P<.0001) compared with trainees. Few trainees or attendings were confident in their ability to change patients' behaviors. Predictors of confidence in counseling for exercise included the provider's own exercise time of > 150 minutes per week, being overweight, and reported adequate training in counseling. Only adequate training in counseling was a predictor of strong self-efficacy for counseling in diet. Many physicians lack confidence in their ability to counsel patients regarding lifestyle. Personal behaviors including regular exercise and better training in counseling techniques may improve patient counseling.

Differences in mortality among Mexican-American, Puerto Rican, and Cuban-American dialysis patients in the United States.

BACKGROUND: The Hispanic ethnic group is heterogeneous, with distinct genetic, cultural, and socioeconomic characteristics, but most prior studies of patients with end-stage renal disease focus on the overall Hispanic ethnic group without further granularity. We examined survival differences among Mexican-American, Puerto Rican, and Cuban-American dialysis patients in the United States. STUDY DESIGN: Prospective observational study. SETTING & PARTICIPANTS: Data from individuals randomly selected for the End-Stage Renal Disease Clinical Performance Measures Project (2001 to 2005) were examined. Mexican-American (n = 2,742), Puerto Rican (n = 838), Cuban-American (n = 145), and Hispanic-other dialysis patients (n = 942) were compared with each other and with non-Hispanic (n = 33,076) dialysis patients in the United States. PREDICTORS: Patient characteristics of interest included ethnicity/race, comorbidities, and specific available laboratory values. OUTCOMES: The major outcome of interest was mortality. RESULTS: In the fully adjusted multivariable model, 2-year mortality risk was significantly lower for the Mexican-American and Hispanic-other groups compared with non-Hispanics (adjusted hazard ratio, 0.79; 95% confidence interval, 0.73 to 0.85; adjusted hazard ratio, 0.81; 95% confidence interval, 0.71 to 0.92, respectively). Differences in 2-year mortality rates within the Hispanic ethnic groups were statistically significant (P = 0.004) and ranged from 21% lower mortality in Mexican Americans to 3% higher mortality in Puerto Ricans compared with non-Hispanics. LIMITATIONS: Include those inherent to an observational study, potential ethnic group misclassification, and small sample sizes for some Hispanic subgroups. CONCLUSION: Mexican-American and Hispanic-other dialysis patients have a survival advantage compared with non-Hispanics. Furthermore, Mexican Americans, Cuban Americans, and Hispanic others had a survival advantage compared with their Puerto Rican counterparts. Future research should continue to examine subgroups within Hispanic ethnicity to understand underlying reasons for observed differences that may be masked by examining the Hispanic ethnic group as only a single entity.