Rationale and Design of the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) at the University of California Los Angeles
Gregg C. Fonarow, MD and Anna Gawlinski, DNSc
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Background
Consistent and compelling clinical trial evidence has demonstrated that risk-factor modification and treatment can markedly decrease the risk of future coronary events and prolong survival in patients with documented CAD.
Despite this clear and consistent evidence, secondary-prevention medical therapies are underutilized in patients receiving conventional care.
To address this issue, a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), was established and implemented at UCLA Medical Center starting in 1994.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Program Overview (1)
The Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) focused on initiation of:
aspirin
cholesterol-lowering therapy (statins) titrated to achieve an LDL-C of < 100 mg/dL
beta-blocker
ACEI
This was done in conjunction with diet, exercise and smoking cessation counseling before hospital discharge in patients with established coronary artery disease
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Program Overview (2)
Implementation of CHAMP involved the use of:
a focused treatment guideline
standardized admission orders
educational lectures by local thought leaders
tracking/reporting of treatment rates
To assess the impact of the program, treatment rates and clinical outcomes were compared in patients discharged in the 2-year period before and after CHAMP was implemented.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (1)
Aspirin
Patients should continue on 81-325 mg aspirin/day indefinitely after discharge.
Cholesterol-Lowering Medications:
Patients with CAD should be started on an HMG-CoA reductase inhibitor to lower cholesterol and treat the underlying atherosclerosis disease process. Starting dose should be the dose estimated to achieve and LDL < 100 mg/dL based on the lipid panel.
Beta Blockers:
These agents should be considered in all patients with CAD, because they reduce the risk of MI and make it more likely that a patient will survive an infarction. Use target doses as clinically tolerated.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (2)
ACE Inhibitors:
These agents have potent vascular and cardiac protective effects. These agents are potentially indicated in all patients with atherosclerosis. All patients with myocardial infarction without contraindications should be started on ACEIs within 24 hours and treated long term. Use target doses.
Nitrates:
These agents should be considered second-line agents after b-blockers for the symptomatic control or angina. There is no long term data showing that nitrates improve prognosis in patients with CAD, so their use is simply for symptom relief.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (3)
Calcium Antagonists:
These agents decrease chest pain but do not decrease the risk of a cardiac event or improve survival. They should, in general, not be prescribed to patients with known CAD.
Antiarrhythmic Agents:
Type I antiarrhythmic agents increase the risk of sudden death in patients with CAD. These agents should be avoided in all patients with CAD except those with implantable cardioverter defibrillators or in whom the risk/benefit ratio has been carefully considered. Amiodarone should be considered the only safe antiarrhythmic agent in patients with CAD.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (4)
Exercise:
Patients should receive specific instructions for a daily aerobic exercise program. Either a home-based program or a supervised cardiac rehabilitation can be recommended. This is an essential component of the management of patients with CAD and is highly effective in preventing subsequent cardiac events.
Smoking Cessation:
Particular attention should be paid to smoking cessation as patients who continue to smoke after presenting with unstable angina have 5.4 times the risk of death from all causes compared with patients who stop smoking. Patients should be offered intensive smoking cessation during hospitalization. This should include both physician and nurse counseling focusing on relapse prevention.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (5)
Diet:
Studies with statins that have demonstrated reduction in mortality, have utilized these medications in conjunction with dietary counseling. Patients and family members, if available, should receive counseling on the NCEP Step 2 Diet during the hospitalization. Information on the outpatient dietary modification programs available should also be provided.
Patient Education:
The patient and his or her family member or advocate should be instructed on the use of medications and monitoring of symptoms. The purpose, dose, and major side effects of each medication prescribed should be explained. Written medication sheets and a medication schedule should be provided along with instructions on what to do if either persistent side effects or recurrent symptoms occur.
Am J Cardiol 2000;85:10A-17A
CHAMP ~ Medical Regimen for Patients with Atherosclerosis (6)
Follow-up:
Continuation of the therapies targeting the underlying atherosclerosis disease process markedly improves clinical outcome in patients with atherosclerosis.
The continued beneficial therapies prescribed should be strongly reinforced during patient follow-up.
A fasting lipid panel should be obtained at 6 weeks to evaluate whether target lipid levels have been achieved and to guide cholesterol-lowering medication dosing adjustments.
Am J Cardiol 2000;85:10A-17A
Atherosclerosis
Clinical
Ultrasound
Stress Test
Angiographic
Coronary
Carotid
Peripheral
Admission Lipid Panel, LFTs
Aspirin, Beta Blocker, ACEI,
HMG CoA Reductase Inhibitor
Exercise and Dietary Counseling
LDL > 100 mg/dL
LDL < 100 mg/dL
Advance Dose and/or
Add Niacin, Resin
Recheck in 6 weeks
Continue Treatment
Recheck in 3-6 months
Inpatient Hospitalization
Initial Outpatient Encounter
Am J Cardiol 2000;85:10A-17A
CHAMP Algorithm for Patients with Clinically Evident Atherosclerosis
CHAMP ~ Safety of Initiating Statins During Hospitalization
Primary Diagnosis n Admit Discharge Abnormal Rehosp
Statin Rx, % Statin, Rx, % LFT* due to Rx
Unstable angina 224 14 82 1 0
Acute MI 302 8 86 0 0
Chest pain 326 15 74 0 0
PTCA 340 8 92