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(Media-Newswire.com) – HOUSTON — ( April 5, 2011 ) — New guidelines for the management of patients with unstable angina and non-ST-elevation myocardial infarction ( termed acute coronary syndromes ) have been released by the American College of Cardiology and the American Heart Association. The guidelines were created by a consortium of national experts including a cardiologist from Baylor College of Medicine.

“This important document is an update of the 2007 ACC/AHA guidelines. We examined past recommendations, reviewed the clinical data that accrued since then, and created the most updated set of recommendations that can provide guidance for physician in their patient care,” said Dr. Hani Jneid, assistant professor of medicine and interventional cardiologist at Baylor College of Medicine and the Michael E. DeBakey VA Medical Center. Dr. Jneid was part of the 15-member writing group, led by Dr. R. Scott Wright, professor of medicine at the Mayo Clinic.

Leading cause of death
Unstable angina occurs when the heart doesn’t get enough blood flow and oxygen, as a result of blockage in one or more of the coronary arteries. This results in chest discomfort, and when prolonged beyond a 20-30 minute period, may progress into myocardial infarction ( or a heart attack ) with death of heart muscle cells. Those guidelines therefore address one of the most commonly encountered clinical conditions and a leading cause of death and morbidity in the United States and the Western World.

Jneid indicated that the guidelines have been updated with a plethora of new recommendations. These include, but are not limited to, recommendations pertinent to early hospital care, such as the timing of cardiac catheterization after an acute coronary syndrome, the use of intravenous anti-platelet and anticoagulant medications, and especially the clinical application of prasugrel, a novel oral anti-platelet drug. New recommendations pertinent to patients with diabetes and chronic kidney disease, as well as recommendations for quality of care and outcome monitoring after an acute coronary syndrome have also been proposed.

Clinically relevant changes
“Our multifaceted group worked tirelessly to review the literature and dissect clinical studies and experimental evidence to come up with the meticulous and clinically relevant changes,” Jneid said. “This process of periodically updating Guidelines is very important to patient care, especially in the dynamic and rapidly evolving field of cardiovascular medicine. The careful revisions and scrutiny of the document and the choice of unbiased and balanced team of experts are all a testimony of the high standards set by the ACC and AHA in constructing these guidelines, as supported by report of the Institutes of Medicine last month.”

In addition to Drs. Scott and Jneid, the national expert panel is made up of Drs. Jeffrey Anderson, Cynthia Adams, Charles Bridges, A. Michael Lincoff, Donald Casey, Eric Peterson, Steven Ettinger, George Philippides, Francis M Fesmire, Pierre Theroux, Theodore Ganiats, Nanette Wenger and James Zidar. Of note, this guidelines update was created in collaboration with prominent medical organizations, including the American Academy of Family Physicians, the American College of Emergency Physicians, the Society for Cardiac Angiography and Interventions, and the Society of Thoracic Surgeons.

The 2011 focused update will be published in the Journal of the American College of Cardiology and Circulation: Journal of the American Heart Association. It has been released online ahead of print on the ACC and AHA web sites.

A UCLA-led study has found that adherence to national guideline–recommended therapies for heart failure in an outpatient practice setting significantly lowered the mortality rate of heart failure patients.

The findings are posted in the April 4 online edition of the journal Circulation.

This is one of the first studies to examine how conformity with current and emerging heart-failure quality measures can impact patient survival and outcomes in the outpatient setting.

A chronic, progressive disease, heart failure impacts millions and results in morbidity, death, the use of significant health care resources, and significant costs. While quality-of-care measures based on national guidelines from the American College of Cardiology and the American Heart Association have been developed, and while prior studies have shown that performance-improvement initiatives substantially improve conformity with these measures, it was unclear if these efforts could improve survival in the real-world clinical practice setting.

“This study establishes a strong process-of-care–clinical outcome link and provides evidence that specific heart failure therapies effectively improve patient survival in an outpatient setting,” said the study’s first author, Dr. Gregg C. Fonarow, UCLA’s Elliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center at the David Geffen School of Medicine at UCLA. “These results have significant clinical and public health implications in helping track and improve quality of care and heart-failure patient outcomes.”

For the study, researchers examined data on 15,177 heart failure patients seen at 167 cardiology practice clinics in the U.S. The data was taken from a national quality improvement program called the Registry to Improve the Use of Evidence-Based Heart Failure Therapies in the Outpatient Setting (IMPROVE HF).

Researchers reviewed medical records at the beginning of the implementation of the IMPROVE program and followed up at 12 and 24 months to assess the relationship between adherence to seven nationally recommended treatment measures and patient outcomes.

The seven measures assessed included:

• Three types of heart failure medications, including beta blockers, aldosterone antagonists, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers.
• The use of cardiac resynchronization therapy, a device that helps coordinate heart contractions.
• Anticoagulant therapy for atrial fibrillation, to prevent clot formation in patients with an irregular heart beat.
• The use of implantable cardioverter-defibrillator devices, to deliver electrical shocks if potentially fatal heart rhythm abnormalities occur.
• Heart-failure patient education.

At 24 months, 11,621 of the 15,177 patients, or 76.6 percent, had documented follow-up in the medical records. Patients represented a broad range of heart failure needs, with some qualifying for all seven measures and others just one or two.

Researchers found that six out of the seven individual measures were associated with significantly improved patient survival over 24 months. The odds of mortality reduction ranged from 31 percent for anticoagulant therapy to 55 percent for beta blocker use, compared with eligible patients who did not receive these therapies.

In a summary score reflecting adherence to the quality measures, each 10 percent increase in the composite score was associated with 13 percent lower odds of 24-month mortality.

Researchers also looked at an “all or nothing” score that found patients who received all the therapies for which they were eligible had 38 percent lower odds of mortality, compared with patients who did not receive one or more of the therapies for which they were qualified.

Previous research by this team showed how the use of IMPROVE HF, a performance-improvement intervention program, helped increase adherence to these national guideline–related therapies but didn’t address the impact on patient outcomes.

The current study provides definitive evidence that complying with measures based on six out of seven of these national guideline therapies is linked to favorable clinical outcomes, with lower mortality over 2 years.

“Adhering to these critical, evidence-based, national guideline–recommended treatments for heart failure truly made an important difference in real-world heart-failure patient survival,”

Fonarow said. “This research puts quality-improvement interventions front and center as an effective means to improve outcomes for outpatients with heart failure.”

Fonarow added that the next step is to implement performance-improvement intervention programs in every outpatient practice in which heart failure patients are cared for to further enhance adherence to these recommended therapies and to improve clinical outcomes.

Currently, two guideline-recommended therapies, implantable cardioverter-defibrillator devices and cardiac resynchronization therapy, are not included as national heart-failure performance measures. According to Fonarow, the link to improved survival demonstrated with these two measures suggests these are valid and useful measures of heart failure quality.

The only measure that was not associated with improved 24-month survival was use of aldosterone antagonists. More study will need to address whether this is a useful heart-failure quality measure.

Medtronic Inc., a manufacturer of cardiac resynchronization therapy and implantable defibrillator devices, provided financial and material support for the IMPROVE HF registry. The company had no role or input in the selection of end-points or quality measures used in the study.

Fonarow has received honoraria and consultant fees from Medtronic. Additional author financial disclosures are listed in the study manuscript.

Additional authors included Nancy M. Albert, Ph.D., Cleveland Clinic Foundation; Anne. B. Curtis, University of South Florida College of Medicine; Dr. Mihai Gheorghiade, Northwestern University; Dr. J. Thomas Heywood, Scripps Clinic; Yang Liu, Medtronic Inc.; Dr. Mandeep R. Mehra, University of Maryland; Dr. Christopher M. O’Connor, Duke University Medical Center; Dr. Dwight Reynolds, University of Oklahoma Health Sciences Center; Dr. Mary Norine Walsh, the Care Group, LLC (Indiana); and Dr. Clyde W. Yancy, Baylor University Medical Center.