CLINICAL
NEWS JOURNAL WRAP
Kim Eagle, MD, and the editors of ACC.org’ present
relevant articles taken from various journals.
Low Referral Rates,
Participation in
Cardiac Rehab
After MI
Cholesterol Goals in CV Practice
While a majority of patients meet
cholesterol goals, there is still room
for improvement, says a recent study
published in the American Journal of
Cardiology.
The study included 146,604 patients with dyslipidemia enrolled in the
National Cardiovascular Data Registry
(NCDR) PINNACLE Registry from
July 1, 2008, to Dece. 31, 2010. Of
this population, 36,188 patients had
a history of diabetes mellitus (DM)
and 80.4% were being treated with
lipid-lowering medications. Using National Cholesterol Education Program
(NCEP) goal definitions, low-density
lipoprotein cholesterol (LDL-C), nonhigh-density lipoprotein cholesterol
(non-HDL-C), and both LDL-C and
non-HDL-C goals in the overall cohort
were achieved by 102,245 (73%),
107,211 (73.4%), and 100,638
(68.9%) patients, respectively.
Patients more likely to have LDL-C
and non-HDL-C levels at NCEP goals
were younger and male. Patients
with myocardial infarction and most
NCEP coronary heart disease risk
equivalents such as previous stroke,
peripheral artery disease, or transient
ischemic attack, were less likely to
have LDL-C and non-HDL-C levels at
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CardioSource WorldNews
NCEP goals. A history of DM was a
significant predictor of having nonHDL-C and of having both an LDL-C
and non-HDL-C levels at NCEP goals.
More than two thirds of patients taking statins had both LDL-C and nonHDL-C levels at NCEP goals. Those
receiving most classes of cardiovascular pharmacotherapy were more likely
to have lipid levels at goals. Predictors
of LDL-C goal attainment did not differ for those for non-HDL-C.
“As practice is impacted by newer
guidelines, data from the NCDR’s
quality improvement PINNACLE
Registry can benchmark cardiology
practice,” the authors, led by Sarah
A. Spinler, PharmD, write. They add
that close monitoring may be required
after the start of statin therapy in the
patients who were found to be less
likely to achieve goal levels.
“Although the percentage of patients with levels at NCEP individual
goals is high, achieving both LDL-C
and non-HDL-C goals occurs in <
70% of patients, so there is room for
improvement should both goals be
considered primary,” they conclude.
Spinler SA, Cziraky MJ, Willey VJ, et al. Am J
Cardiol. 2015;116:547-53.
Although current guidelines recommend cardiac rehabilitation following
acute myocardial infarction (AMI), rates
of participation are low even among
those referred to these programs, according to a research letter published
Aug. 3 in JAMA: Internal Medicine.
Cardiac rehabilitation programs are
multifaceted outpatient interventions
that include individualized exercise
programs, health education, and support
focused on cardiovascular risk reduction
and medication adherence. Patients typically attend two to three sessions weekly
for up to 36 sessions. Cardiac rehabilitation improves survival after AMI and is
associated with improvements lifestyle,
functional capacity and quality of life.
Researchers examined records
from 58,269 eligible patients age 65
or older enrolled in the ACC’s ACTION
Registry-GWTG linked with Centers for
Medicare and Medicaid Services data
between January 2007, and December
2010. Of those patients, 36, 376 (62%)
were referred to cardiac rehabilitation at
the time of hospital discharge. Of those
referred, 11,862 (about 33%) attended
at least one session within the following
year. Among those not initially referred,
1,795 (8%) attended at least one session.
The median number of sessions
attended among patients participating
in rehab was 26, with 3,305 (24%) attending at least 36 sessions and 1,188
(about 9%) attending fewer than five sessions. Among the 58,269 patients in the
cohort, 13,657 (about 23%) attended
one or more cardiac rehabilitation sessions, and 3,175 (about 5%) completed
36 sessions or more.
Patients who participated in at least
one session tended to be younger, male,
white, and nonsmokers, with fewer comorbidities. Participation in cardiac rehab
was also more common among patients
treated with coronary artery bypass graft
(about 4%) than among those treated
with percutaneous coronary interventions
(36%) or medical management (16%).
“Our analysis identifies opportunities
to improve the use of cardiac rehabilitation by older adults,” says Jacob A. Doll,
MD, the research letter’s lead author and
a fellow at the Duke Clinical Research
Institute. “Quality improvement efforts
should focus not only on increasing
referral rates but also on addressing
barriers to attending sessions, such as
travel distance, co-payments, and lack of
coordination between inpatient and outpatient clinicians. Alternative methods,
such as home-based programs, may be
needed to improve participation rates.”
In an accompanying commentary,
Donna M. Polk, MD, MPH, and
Patrick T. O’Gara, MD, both of the
Cardiovascular Division at Brigham
and Women’s Hospital, write that
cardiac rehabilitation programs are
“grossly underused,” adding that referral, while important, does not guarantee that a patient will attend all 36
sessions, even though the survival of
those patients is better than for those
who leave the program prematurely
To address this problem, they
point to patient-centered approaches,
including the selective use of homebased exercise programs coupled with
smartphone applications to monitor
heart rate, blood pressure, and other
vital signs. Such programs also include
internet, mobile phone, and/or textbased coaching. Social media, they say,
“adds another layer of communication
to optimize patient adherence and may
provide a friendly competition among
participants.” Early research on these
innovations shows significantly higher
rates of participation and completion
than for traditional programs.
Polk and O’Gara stress the importance of moving toward digital and ehealth strategies. “Wide-scale change,”
they emphasize, “will require patients,
clinicians, insurers, and health systems to adopt and catch up with what
is already digitally achievable.”
Doll JA, Hellkamp A, Ho PM, et al.
JAMA Int Med. 2015;[Epub ahead of print]
Continued on page 21
September 2015