CVD Guidelines Design and Implementation2011

8/12/2019 CVD Guidelines Design and Implementation2011

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CVD Prevention Guidelines:Design and Implementation

Nathan D. Wong, PhD, FACC, FAHAProfessor and Director

Heart Disease Prevention Program

Division of Cardiology

University of California, Irvine, CA USAPresident, American Society for Preventive Cardiology


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Scientific Statements

- increase knowledge and awareness byhealthcare professionals of effective, state-of-the art science related to the causes,prevention, detection, or management ofcardiovascular diseases and stroke.

- represent the consensus of the leadingexperts in cardiovascular disease andstroke.

- undergo blinded peer review and arereviewed and approved by the AHAScience Advisory and CoordinatingCommittee (SACC), the highest scientificbody of the AHA.


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Guidelines

The Institute of Medicine defines a guideline assystematically developed statements to assistpractitioner and patient decisions aboutappropriate health care for specific clinicalcircumstances.

The AHA often develops practice guidelines inconjunction with the American College ofCardiology (ACC), but also may develop themalone or in partnership with other organizationsas appropriate.

All guidelines adhere to the levels of evidenceand classes of recommendation as establishedby the ACC/AHA Guidelines Task Force.

All guidelines undergo peer review and arereviewed and approved by the AHA SACC.


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Overview of AHA CVDPrevention Guidelines

Diet and Lifestyle Recommendations: Revision2006

AHA/ACC Guidelines for Secondary Prevention forPatients With Coronary and Other AtheroscleroticVascular Disease: 2006 Update

Guidelines for Prevention of Stroke in PatientsWith Ischemic Stroke or Transient Ischemic Attack

American Heart Association Guide for ImprovingCardiovascular Health at the Community Level

AHA Guidelines for Primary Prevention ofCardiovascular Disease and Stroke: 2002 Update

Heart Association Guidelines for WeightManagement Programs for Healthy Adults
http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158http://circ.ahajournals.org/cgi/content/full/113/19/2363http://circ.ahajournals.org/cgi/content/full/113/19/2363http://circ.ahajournals.org/cgi/content/full/113/19/2363http://stroke.ahajournals.org/cgi/content/full/37/2/577http://stroke.ahajournals.org/cgi/content/full/37/2/577http://circ.ahajournals.org/cgi/content/full/107/4/645http://circ.ahajournals.org/cgi/content/full/107/4/645http://circ.ahajournals.org/cgi/content/full/106/3/388http://circ.ahajournals.org/cgi/content/full/106/3/388http://www.americanheart.org/presenter.jhtml?identifier=1226http://www.americanheart.org/presenter.jhtml?identifier=1226http://www.americanheart.org/presenter.jhtml?identifier=1226http://www.americanheart.org/presenter.jhtml?identifier=1226http://circ.ahajournals.org/cgi/content/full/106/3/388http://circ.ahajournals.org/cgi/content/full/106/3/388http://circ.ahajournals.org/cgi/content/full/107/4/645http://circ.ahajournals.org/cgi/content/full/107/4/645http://stroke.ahajournals.org/cgi/content/full/37/2/577http://stroke.ahajournals.org/cgi/content/full/37/2/577http://circ.ahajournals.org/cgi/content/full/113/19/2363http://circ.ahajournals.org/cgi/content/full/113/19/2363http://circ.ahajournals.org/cgi/content/full/113/19/2363http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.176158


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Overview of ACCF/AHA

Performance Measurement Sets


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Attributes of PerformanceMeasures


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Classification of Recommendationsand Levels of Evidence


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Class I

Benefi t >>> Risk

Procedure ortreatment SHOULD

be performed or

administered

Class IIa

Benefi t >> Risk

Add i t ional studies

wi th focused

ob ject ives needed

IT IS REASONABLEto perform

procedure or

administertreatment

Class IIb

Benefit Risk

Ad di t ional studies

wi th broad

object ives n eeded;

Add i t ional registry

data wou ld be

helpfu l

Procedure ortreatment

MAY BECONSIDERED

Class III

Risk Benefit

No addi t ional studies

needed

Procedure ortreatment should

NOT be performed or

administeredSINCEIT IS NOT HELPFUL

AND MAY BEHARMFUL

Applying Classification of

Recommendations and Level of

Evidence


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Level A

Mul tip le (3-5)

popu la tion r isk

strata evaluated

General

consis tency ofdirect ion and

magnitud e of

effect

Class I

Recommendationthat procedureor treatment is

useful/ effective

Sufficientevidence from

multiplerandomized

trials or meta-analyses

Class IIa

Recommendationin favor of

treatment orprocedure beinguseful/ effective

Some conflictingevidence from

multiplerandomized


Class IIb

Recommendations usefulness/

efficacy less wellestablished

Greaterconflicting

evidence frommultiple

randomizedtrials or meta-

analyses

Class III

Recommendationthat procedure

or treatment notuseful/ effective

and may be

harmful

Sufficientevidence from

multiplerandomized




Evidence


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Level B

Lim ited (2-3)

popu la t ion r isk

strata evaluated

Class I

Recommen-dation that

procedure ortreatment is

useful/ effective

Limited evidencefrom single

randomized trialor non-

randomizedstudies

Class IIa

Recommen-dationin favor of

treatment orprocedure being

useful/ effective

Some conflictingevidence from

singlerandomized trial

or non-randomized

studies

Class IIb

Recommen-dations

usefulness/efficacy less well

established

Greater conflictingevidence from

singlerandomized trial

or non-randomized

studies

Class III

Recommen-dationthat procedure or

treatment notuseful/effective

and may beharmful

Limited evidencefrom single

randomized trialor non-

randomizedstudies



Evidence


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Evidence

Level C

Very lim ited (1-2)

popu la t ion r isk

strata evaluated

Class I

Recommen-dation that

procedure or

treatment isuseful/ effective

Only expertopinion, case

studies, orstandard-of-

care

Class IIa

Recommendationin favor of

treatment or

procedure beinguseful/effective

Only divergingexpert opinion,case studies, orstandard-of-care

Class IIb

Recommen-dations

usefulness/

efficacy less wellestablished

Only divergingexpert opinion,case studies, orstandard-of-care

Class III

Recommendationthat procedure or

treatment not

useful/effectiveand may beharmful

Only expertopinion, case

studies, orstandard-of-care


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AHA / ACCF Primary PreventionRevised Statement September 2009

Circulation, September 2009


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Numerator = Patients with assessment of dietand physical activity occurred in the past 2 years

Denominator= Patients aged 8-80 years at

beginning of assessment period

Lifestyle / Risk Factor Screening


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Numerator = Patients who were advised to eata healthy diet at least once in the past 2 years

DenominatorAll patients 18 to 80 years of

age at start of the measurement period

Dietary Intake Counseling


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AHA Scientific Statement: Diet and

Lifestyle Recommendations Revision 2006


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Numerator= Patients who were advised at least

once within the past 2 years to engage in regularphysical activity

DenominatorAll patients 18 to 80 years of age at

start of the measurement period

Physical Activity Counseling


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Numerator = Patients who were queried about

tobacco use 1 or more times in the past 2 years

Denominator

All patients 18 years of age orover at start of the measurement eriod

Smoking / Tobacco Use


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Numerator = Patients identified as tobacco userswho received cessation intervention

Denominator= All patients aged 18 years and over

at start of measurement period identified as tobacco

users

Smoking / Tobacco Cessation


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Weight / Adiposity Assessment

Numerator = Patients for whom weight andBMI and/or WC is documented at least once in

the last 2 years

Denominator= All patients 18-80 years of age

at start of measurement period


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Weight Management

Numerator= All patients who were counseled

on weight management at least once withinthe past 2 years

Denominator= All patients 18-80 years of age

at start of measurement period with BMI >30

or WC >102 cm (men) or >88 cm (women)


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Blood Pressure Measurement

Numerator= Patients for whom blood pressuremeasurement was recorded at least once in the past

2 years

Denominator = All patients aged 18-80 years at


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Blood Lipid Measurement

Numerator= Patients with at least 1 fasting lipid profile

performed within the past 5 years

Denominator = Men aged 35-80 or Women aged 45-80

with at least 1 risk factor, 2+ visits


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Gl b l Ri k E ti ti


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Global Risk Estimation

Numerator (quality improvement only):patients for

whom 10-year risk of CHD is recorded at least once in the

last 5 years

Denominator: Men aged 35-80 and women 45-80 free ofCHD but with at least one risk factor


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Aspirin use

Numerator ( internal quality improvement only):men

aged 35-80 or women 45-80 advised to use aspirin

Denominator:All men 35-80 or women 45-80 without

CVD but with estimated 10-year CHD risk >=20%


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AHA Secondary Prevention for Patients

with Coronary Artery and Other

Atherosclerotic Vascular Disease

Circulation 2006;113:2363-2372 and

J Am Coll Cardiol 2006;47:2130-2139


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Introduction

Since the 2001 update of the AHA/ACC consensusstatement on secondary prevention, important evidence

from clinical trials has emerged that further supports and

broadens the merits of aggressive risk reduction therapies

This growing body of evidence confirms that aggressivecomprehensive risk factor management improves survival,

reduces recurrent events and the need for interventional

procedures, and improves the quality of life

The secondary prevention patient population includes

those with established coronary and other atherosclerotic

vascular disease, including peripheral arterial disease,

atherosclerotic aortic disease and carotid artery disease.


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Secondary Prevention Definition

Therapy to reduce recurrent cardiovascular events and

decrease cardiovascular mortality in patients with

established atherosclerotic vascular disease

Patients covered include those with establishedcoronary and other atherosclerotic vascular disease,

including peripheral arterial disease, atherosclerotic aortic

disease and carotid artery disease

Individuals with sub-clinical atherosclerosis and patientswhose only manifestation is diabetes are covered in other

guidelines


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Components of Secondary

Prevention

Cigarette smoking cessation

Blood pressure control

Lipid management to goal

Physical activity

Weight management to goal

Diabetes management to goal

Antiplatelet agents / anticoagulants

Renin angiotensin aldosterone system blockers

Beta blockersInfluenza vaccination


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Goal: Complete Cessation and NoExposure to Environmental

Tobacco Smoke

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII

Cigarette Smoking

Recommendations

Ask about tobacco use status at every visit.

Advise every tobacco user to quit.

Assess the tobacco users willingness to quit.

Assist by counseling and developing a plan for

quitting.

Arrange follow-up, referral to special programs,

or pharmacotherapy (including nicotine

replacement and bupropion.

Urge avoidance of exposure to environmental

tobacco smoke at work and home.


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Goal:


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Risk Category LDL-C and non-HDL-C Goal

Initiate TLCConsider

Drug Therapy

High r isk:CHD or CHD riskequivalents(10-year risk >20%)

and

200 mg/dL,

non-HDL-C

should be < 130mg/dL

100mg/dL

>100 mg/dL(


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Lipid Management

Recommendations

Start dietary therapy (


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*Trans fatty acids also raise LDL-C and should be kept at a low intake.

Note: Regarding total calories, balance energy intake and expenditure to maintaindesirable body weight.


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Lipid Management


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Lipid Management

Recommendations

If TG are 200-499 mg/dL, non-HDL-C should be< 130 mg/dL

Further reduction of non-HDL to < 100 mg/dLis reasonable

Therapeutic options to reduce non-HDL-C:More intense LDL-C lowering therapy I (B) orNiacin (after LDL-C lowering therapy) IIa (B) orFibrate (after LDL-C lowering therapy) IIa (B)

If TG are > 500 mg/dL, therapeutic options toprevent pancreatitis are fibrate or niacinbefore LDL lowering therapy; and treat LDL-Cto goal after TG-lowering therapy. Achievenon-HDL-C < 130 mg/dL, if possible





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Weight Management Recommendations


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Weight Management Recommendations


Goal: BMI 18.5 to 24.9 kg/m2

Waist Circumference: Men: < 40 inches

Women: < 35 inches


Assess BMI and/or waist circumference on each visit

and consistently encourage weight maintenance/

reduction through an appropriate balance of physical

activity, caloric intake, and formal behavioral programs

when indicated.

If waist circumference (measured at the iliac crest)

>35 inches in women and >40 inches in men initiate

lifestyle changes and consider treatment strategies for

metabolic syndrome as indicated.

The initial goal of weight loss therapy should be to

reduce body weight by approximately 10 percent from

baseline. With success, further weight loss can be

attempted if indicated.

*BMI is calculated as the weight in kilograms divided by the body surface area in meters2.Overweight state is defined by BMI=25-30 kg/m2. Obesity is defined by a BMI >30 kg/m2.


Di b t M llit R d ti


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Diabetes Mellitus Recommendations


Goal: Hb A1c < 7%


Lifestyle and pharmacotherapy to achieve near

normal HbA1C (


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Antiplatelet Agents / AnticoagulationRecommendations


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Cl id l R d ti


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Start and continue clopidogrel 75 mg/din combination with aspirin

for post ACS or post PCI with stent

placement patients for up to 12months

for post PCI-stented patients

>1 month for bare metal stent,

>3 months for sirolimus-eluting stent

>6 months for paclitaxel-eluting stent

*Clopidogrel is generally given preference over Ticlopidine because of a superior safety profile


Clopidogrel Recommendations


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Anticoagulation Recommendations

Manage warfarin to international normalizedratio 2.0 to 3.0 for paroxysmal or chronicatrial fibrillation or flutter, and in post-MIpatients when clinically indicated (e.g., atrialfibrillation, LV thrombus.)

Use of warfarin in conjunction with aspirinand/or clopidogrel is associated with

increased risk of bleeding and should bemonitored closely




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ACE Inhibitor Recommendations


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ACE Inhibitor Recommendations

Use in all patients with LVEF < 40%, andthose with diabetes or chronic kidneydisease indefinitely, unless contraindicated

Consider for all other patients

Among lower risk patients with normal LVEFwhere cardiovascular risk factors are wellcontrolled and where revascularization hasbeen performed, their use may beconsidered optional



ACE=Angiotensin converting enzyme, LVEF= left ventricular ejection fraction


Angiotensin Receptor Blocker


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Angiotensin Receptor Blocker

Recommendations

Use in patients who are intolerant of ACEinhibitors with HF or post MI with LVEF lessthan or equal to 40%.

Consider in other patients who are ACEinhibitor intolerant.

Consider use in combination with ACE

inhibitors in systolic dysfunction HF.


ACE=Angiotensin converting enzyme inhibitor, LVEF=Left Ventricular Ejection fraction, HF=Heart

failure, MI=Myocardial infarction



Aldosterone Antagonist


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Aldosterone Antagonist

Recommendations

III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIIIUse in post MI patients, without significantrenal dysfunctionor hyperkalemia, who arealready receiving therapeutic doses of an

ACE inhibitor and beta blocker, have an LVEF< 40% and either diabetes or heart failure

ACE=Angiotensin converting enzyme inhibitor, LVEF=Left Ventricular Ejection fraction,

MI=Myocardial infarction

*Contraindications include abnormal renal function (creatinine >2.5

mg/dL in men or >2.0 mg/dL in women) and hyperkalemia (K+ >5.0

meq/L)


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-blocker Recommendations

blocker Recommendations


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III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII Start and continue indefinitely in all post MI,ACS, LV dysfunction with or without HFsymptoms, unless contraindicated.

Consider chronic therapy for all otherpatients with coronary or other vasculardisease or diabetes unless contraindicated.

*Precautions but still indicated include mild to moderate asthma or chronic obstructive pulmonary

disease, insulin dependent diabetes mellitus, severe peripheral arterial disease, and a PR

interval >0.24 seconds.

MI=Myocardial infarction, HF=Heart Failure

-blocker Recommendations


I fl V i ti


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Influenza Vaccination

Patients with cardiovascular diseaseshould have influenza vaccination


The Need to Implement Secondary


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The Need to Implement Secondary

Prevention

Multiple studies of the use of these recommended therapies in

appropriate patients continue to show that many patients in whom

therapies are indicated are not receiving them in actual clinical

practice.

The AHA and ACC urge that in all medical care settings where these

patients are managed that programs to provide practitioners withuseful reminder clues based on the guidelines, and continuously

assess the success achieved in providing these therapies to the

patients who can benefit from them be implemented.

Encourage that the AHAs Get With the Guidelines and/or ACCsGuidelines Applied to Practice Programs be instituted to identify

appropriate patients for therapy

AHA GWTG P


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AHA GWTG Program

GWTG is a national initiative of the AHA to improveguidelines adherence in patients hospitalized with

cardiovascular disease.

GWTG uses collaborative learning sessions,

conference calls, e-mail and staff support to assisthospital teams improve acute and secondary

prevention care systems.

A web-based Patient Management Tool is used for

point of care data collection and decision support,on-demand reporting, communication and patient

education.

SIMPLE, ONE PAGE, ON-LINE FORM


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Demographics6 clicks

Clinical/Lab

8 clicks

Discharge

meds andinterventions7 clicks

Interactivelychecks

patientsdata with the

AHA guidelines

2001 Outcome Sciences, Inc.


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S d P i C l i


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Evidence confirms that aggressive comprehensive

risk factor management improves survival, reduces

recurrent events and the need for interventional

procedures, and improves the quality of life for thesepatients.

Every effort should be made to ensure that patients

are treated with evidence-based, guideline

recommended, life-prolonging therapies in theabsence of contraindications or intolerance.

Secondary Prevention Conclusions


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Patients hospitalized with cardiovascular event are atparticularly high risk for recurrent events, hospitalizations,and cardiovascular death.

Fortunately, there are a number of evidence based andhighly effective therapies which can significantly improveacute long-term care outcomes and reduce recurrentevents.

While the AHA, ACC, and ASA Guidelines provideevidence-based recommendations for cardiovascular care,adherence to these guidelines is both incomplete andhighly variable.

Issue/Challenge


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AHA Quality Improvement Programs:

Get With The Guidelines-Stroke

Get With The Guidelines-Heart Failure

ACTION Registry-- GWTG

Get With The Guidelines-Outpatient(Nov ember 2009)

Mission: Lifeline National Registry of CPR

Co-promoted programs associated with AHA/ASA Quality

programs:

NCQA/AHA/ASA Heart and Stroke Recognition Program Disease Specific Care Certification for Primary Stroke

Centers (The Joint Commission/AHA/ASA)

Advanced Certification in Heart Failure (TJC/AHA)

AHAs Quality Portfolio


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Attend a GWTG workshop

Designate a champion from hospital

Recruit care team for implementation

Enter baseline data into the Patient Management Tool Institute care paths, standing orders and dischargeprotocols that are consistent with the ASA/AHAguidelines

Utilize the Patient Management Tool to record and

improve patient care. Achieve Performance Award levels

Get With The Guidelines:Elements of Success


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How is Health Integration Technology used by

GWTG to achieve goals?

Patient Management ToolTM

Easy to use, web-based, real-time data management anddecision support tool

Incorporates proven, decision-support-guidelinereminder checks

Opportunity for concurrent data collection-access to real-time data collection and report generation to supportrapid CQI

Automatically generated, patient-specific educationmaterials customized for the patient

Core measure reporting options


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AHA GWTG-HF Web Based

Patient Management Tool


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Program Progress Reports

GWTG-CAD: Performance


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GWTG CAD: PerformanceMeasures

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Performance Measure

Comp

liance

Baseline 82.1% 83.3% 77.9% 68.8% 72.1% 62.6% 76.9% 56.1%

Current 91.5% 94.2% 94.1% 92.6% 91.6% 98.4% 92.7% 85.8%

ASA within

24 Hours

ASA at

Discharge

Beta Blockers

at Discharge

ACEI or ARB at D/C for

LVSD

Lipid Lowering

Therapy at D/C

for LDL > 100

Smoking Cessation

Counseling

Composite

Performance Measure

100%

Compliance Measure

Baseline = Admissions Jan2002Dec2002 July2009

Current = Admissions Jul2008-Jun2009


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GWTG-HF: Performance Measures

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Performance Measure

Com

pliance

Baseline 69.7% 90.1% 81.2% 87.3% 77.4% 80.1% 60.1%

Current 89.5% 96.7% 91.8% 92.5% 96.1% 92.5% 83.8%

Discharge InstructionsLV Function

Measurement

ACEI or ARB at

D/C for LVSD

Beta Blocker at

D/C for LVSD

Smoking Cessation

Counseling

Composite Performance

Measure

100% Compliance

Measure

Baseline = Admissions Jan2005Dec2005 July 2009

Current = Admissions Jul2008Jun2009


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GWTG P bli ti


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GWTG Publications

2009 through 8/2/09:

13 Published Manuscripts (4 HF, 5 CAD, 3 Stroke, 1 CAD/HF)

23 Abstracts presented at Conferences

(ISC10, ACC6, QCOR7, HFSA0)

Snapshot of GWTG papers in process:

23 Manuscripts: 12 pending Journal decision, 11 in process to Journal

submission

18 Abstracts: 8 pending acceptance at AHA 2009 conference, 10 in process to

manuscript

32 Total Research Proposals in Queue

2008 Results:20 Published Manuscripts (5 HF, 10 CAD, 5 Stroke)

2007 Results:4 Published Manuscripts (1 HF, 3 CAD)


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Hvala - Thank you!


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Hvala - Thank you!For more

information

contact the UCI

Heart DiseasePrevention

Program at:

www.heart.uci.edu

949-824-5561
http://www.heart.uci.edu/http://www.heart.uci.edu/

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CVD Guidelines Design and Implementation2011

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