对NCEP和AHA/ACC指南中采纳的近年来的脂代谢紊乱循证医学进行了总结。
Implementing NCEP and AHA/ACC Guidelines: Impact of New Evidence Gregg C. Fonarow, MD
1970s
1988
Evolution of the NCEP Guidelines
1993
2001
ATP I
ATP II
ATP III
Framingham
MRFIT
LRC-CPPT
Coronary Drug Project
Helsinki Heart Study
CLAS (angio)
Angiographic Trials
(FATS, POSCH, SCOR, STARS, Ornish, MARS)
Meta-Analyses
(Holme, Rossouw)
4S, WOSCOPS, CARE, LIPID, AFCAPS/TexCAPS, VA-HIT, others
Deaths (in Thousands)
79
81
83
87
89
95
99
Years
American Heart Association. 2002 Heart and Stroke Statistical Update. Dallas, Texas: AHA, 2001.
Cardiovascular Disease Deaths: United States 1979–1999
91
97
85
93
Women
Men
NCEP I
NCEP II
NCEP III
Adherence to NCEP Treatment Goals in Patients with CHD: Quality Assurance Program
Sueta CA et al. Am J Cardiol 1999;83:1303-1307.
LDL < 100, on Rx
LDL < 100, no Rx
LDL > 100, on Rx
LDL > 100, no Rx
No LDL, on Rx
No LDL, no Rx
7%
5%
18%
16%
12%
42%
n = 58,890; 140 US practices, chart audit 7/94–10/96
Utilization of Lipid-Lowering Medications at Discharge in Patients with AMI: National Registry of Myocardial Infarction (NRMI) 3
Fonarow GC et al. Circulation 2001;103:38-44.
CV Events
% Discharged on Lipid Therapy
Male (n=83,806)
P<0.0001
Female (n=54,195)
Age (Years)
P<0.0001
P<0.0001
P=NS
P=NS
<55
55–64
65–74
75–84
85+
138,001 patients discharged from 1470 US hospitals, July 1998 to June 1999
CHD Patient "Treatment" Gap
Fonarow GC et al. Circulation 2001;103:38-44. | Sueta CA et al. Am J Cardiol 1999;83:1303-1307. | Pearson TA et al. J Am Coll Cardiol 1998;31:88A. | Pearson TA et al. Arch Intern Med 2000;160:459-467.
Hospital Setting
Outpatient Setting
<40% CV hospitalized patients discharged on Rx
<30% with LDL <100 at 6 months post discharge
Burden of Disease
Burden of Disease
6.3 million annual CHD discharges in the US
25 million CHD patients in the US
NRMI / ACCEPT Data
QAP / L-TAP Data
<50% CHD patients receiving lipid Rx
<20% with LDL <100 (at goal)
CHD Patient Treatment Gap: Community
Pearson TA et al. Arch Intern Med 2000;160:459-467.
18
Provider awareness does not equal successful implementation
95
Physician
Awareness of
NCEP Guidelines
Patient Treated to Goal
Percent
CHD Patient Treatment Gap: Academic Centers
CV Events
% CAD Patients Treated
Brigham and Women’s
(1996)
An academic environment does not equal successful implementation
Abookire SA et al. Arch Intern Med 2001:161:53-58. | Muhlestein JB et al. Am J Cardiol 2001;87:257-261. | Chan AW. Circulation 2002;105:691-696. | Aronow HD et al. J Am Coll Cardiol 2000;35:411A.
LDS
Hospital
(1994–1997)
Cleveland Clinic (1993–1999)
Lipid-Lowering Medication Treatment Rates
PURSUIT Trial Centers (1995–1997)
2003 CAD outpts
600 CAD pts discharged post cath
5052 CAD pts post PTCA
8515 ACS pts
27.1
18
26.5
25.1
Barriers to Implementing Risk Factor Management in Patients with Documented CHD
Physician is focused on acute problems
Time constraints and lack of incentives, including reimbursement
Lack of training including inadequate knowledge of benefits and lack of prescription experience
Lack of resources and facilities
Lack of specialist–generalist communication; passing on responsibility
Adapted from Pearson TA et al. J Am Coll Cardiol 1996;27:1039-1047.
Guidelines and treatment pathways which delay therapy and call for multiple steps, laboratory tests, and time points
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. JAMA 1993;269:3015-3023.
NCEP ATP I and II Guidelines for the Detection and Treatment of Hypercholesterolemia: Secondary Prevention Treatment Algorithm
Clinical event defining CHD
Schedule 6-wk follow-up visit and fasting lipid panel
6-wk follow-up visit
Obtain fasting lipid panel
Review results
Schedule patient for dietary counseling visit
Prescribe AHA Step II Diet
Obtain fasting lipid panel in 3 months
Review results
Schedule patient for further dietary counseling
Obtain fasting lipid panel in 3 months
Review results
Schedule patient for follow-up appt
Prescribe cholesterol-lowering medication
100%
20%
Survey of Secondary Prevention of CHD: Action on Secondary Prevention through Intervention to Reduce Events (ASPIRE)
Bowker TJ et al. Heart 1996;75:334-342.
6 months after MI, 82% of patients had cholesterol >200 mg/dl
ASA
Beta Blocker
Calcium Blocker
ACE Inhibitor
Lipid Lowering
Utilization Rate (%)
85
38
30
26
9
Changing the Therapeutic Target for Atherosclerotic Vascular Disease
Fonarow GC et al. Am J Cardiol 2000;85:10A-17A.
Ischemia as the Target
Antianginal Medications
Calcium Blockers
Nitrates
Beta Blockers
Revascularization
Angioplasty
CABG
Risk factor modification
Atherosclerosis as the Target
Aspirin
Statin
Beta Blocker
ACE Inhibitor
Exercise
Smoking Cessation
Symptom control
Antianginal medications
Revascularization
Lipid Levels as the Target
Atherosclerosis as the Target
Treatment Approach
Measure and treat levels
Only patients with levels above normal benefit
Start on low dose and titrate
Goal is “normal” levels
Benefit same regardless of Rx
Based on epidemiologic and observational data
Find patients with disease or at risk
All patients benefit, regardless of lipid levels
Start on clinical trial–proven doses
Goal is getting on and staying on Rx
Statins have independent benefits
Based on randomized clinical trial evidence
Hospital Phase of Care
Outpatient Phase of Care
Clinical
Ultrasound
Stress Test
Angiographic
Antiplatelet Rx, Beta Blocker
ACE Inhibitor, and Statin
Exercise and Dietary Counseling
LDL ?100 mg/dl
Advance statin dose
and/or add niacin, resin
Continue treatment
Recheck in 6 weeks
Coronary
Cerebral
Peripheral
LDL <100 mg/dl,
HDL >40 mg/dl
Continue treatment
Recheck in 3–6 months
6 weeks: Lipid Panel, LFTs
Patient with Atherosclerosis
UCLA Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP) Algorithm
Fonarow GC et al. Am J Cardiol 2000;85:10A-17A.
Focused Treatment
Guidelines and Algorithm
Preprinted Admit
Order Sheets
Discharge Forms
and Outpt F/U Process
Patient Education
Materials
Focused Lectures
by Opinion Leader
Measurement and
Utilization Reports
Implementation of CHAMP
CHAMP tool kit: www.med.ucla.edu/champ
Fonarow GC et al. Am J Cardiol 2000;85:10A-17A.
Discharge medications for patients presenting to UCLA with acute MI:
NRMI 2 1994–1995 (1369 centers)
Impact of UCLA CHAMP
Fonarow GC et al. Am J Cardiol 2001;87:819-822.
Outpatient-initiated Discontinuation Rate, %
0
8
24
32
48
Weeks
40
16
Barriers to Continuing Risk Factor Management in CHD Patients: Outpatient-Initiated Discontinuation of Lipid-Lowering Medication
Andrade SE et al. N Engl J Med 1995;332:1125-1131.
ASA
Beta Blocker
Calcium Blocker
AC