Both emergency and non-emergency care of cardiovascular disease have continually improved over the past decade, thanks to improved quality of care, novel procedures and better therapies. In particular, research on improved care of cardiovascular disease shows noticeable improvements with a combination of drug and risk factor interventions. Three studies presented today at the American College of Cardiology’s 56th Annual Scientific Session assess how continued improvements in cardiac care can lead to enhanced clinical practice and improved quality of life for patients. The American College of Cardiology Annual Scientific Session is the premier cardiovascular medical meeting, bringing together cardiologists and cardiovascular specialists to further breakthroughs in cardiovascular medicine.
Improved Ten-Year Prognosis of Asymptomatic Patients With Documented Silent Myocardial Ischemia Due to Medical Therapy: The Swiss Interventional Study on Silent Ischemia Type I (SWISSI I) (Presentation Number: 412-4)
Episodes of silent myocardial ischemia, a characteristic of coronary artery disease (CAD), occur in patients when blood flow to the heart is restricted without causing pain. Over time, irreparable damage occurs, bringing the patient closer to life-threatening complications. Study results now verify the value of drug therapy to manage silent myocardial ischemia and help patients maintain their quality of life.
The Swiss Interventional Study on Silent Ischemia Type I (SWISSI I) studied a group of 54 asymptomatic subjects with at least one risk factor for CAD. Consenting patients receiving either anti-anginal drug therapy with risk factor control (n=26), or risk factor control alone (n=28), were followed for an average of 11.2 years. Risk factor control included counseling on eating habits, smoking and exercise, as well as the use of statins for high cholesterol or ACE inhibitors for hypertension, if needed.
During patient follow-up, patients taking anti-anginal therapies had consistently lower rates of exercise-induced ischemia during follow-up and researchers found that cardiac death, non-fatal heart attack, and unstable chest pains requiring medical help occurred considerably less often in patients receiving drug therapy in addition to risk factor control, compared to those without drug therapy (12 vs. 61%, respectively). In addition, global left ventricular ejection fraction remained unchanged in patients taking anti-anginal therapies, in contrast to non-therapy patients where it decreased over time, resulting in a significantly lower ejection fraction value at final follow-up (55.3 vs. 61.1%, respectively).
"This long-term data in asymptomatic silent ischemia patients but no history of CAD shows, for the first time, a beneficial effect of anti-anginal drug therapy on outcome events, reduction in ischemia and preservation of left ventricular function," said Matthias Pfisterer, M.D., of University Hospital in Basel, Switzerland, and lead author of the study. "We were pleased to see that the combination of therapy and risk factor control preserved left ventricular function and increased artery blood flow, and we expect the unprecedented findings to influence future treatments of patients who suffer from CAD without noticeable symptoms or prior diagnosis."
Dr. Pfisterer will present his study on Monday, March 26 at 4:00 p.m. in Hall A.
Who Benefits Financially From Reducing Door-To-Balloon Time in STEMI: Payers or Hospitals? (Presentation Number: 412-6)
The quicker a patient with a ST-elevation myocardial infarction (STEMI, or heart attack) is admitted into the catheterization lab for treatment, the better chances are for not only survival, but also financial savings. A study by researchers at Indiana Heart Physicians and St. Francis Heart Center in Indianapolis, Ind., drew a measurable connection between reduced time for treatment (also known as door-to-balloon time) and reduced overall cost of care.
With the cost of health care on the rise, researchers are trying to establish a more effective model for performing top quality care while being attentive to health care costs. Seeking to understand the potential cost savings of faster door-to-balloon time, researchers analyzed a protocol meant to streamline the process. The protocol required an emergency department physician to activate the catheterization lab and a team of specialized nurses to transfer the patient to the catheterization lab immediately.
Door-to-balloon time data was collected for STEMI patients undergoing emergency percutaneous intervention. The study compared the speed of the process in 60 cases prior to the implementation and 86 cases after implementation. An average of 38 minutes was saved using the protocol and the percentage of patients treated within the recommended 90 minutes increased from 28 percent to 71 percent. In addition, heart attack rates fell by 40 percent and average time spent in the hospital decreased by two days. The financial impact of this quality improvement was substantial with total hospital costs falling by nearly $9,399 per admission. However, the private and public insurance payments to the hospital fell by a greater amount ($9,715 per admission) causing the hospital to lose money with implementation of this quality improvement.
"This study exposed great gains in quality of care for heart attack patients — in a manner that reduced overall health care costs," said Umesh N. Khot, M.D., of Indiana Heart Physicians and St. Francis Heart Center and lead author of the study. "Widespread adoption of our program could dramatically improve the quality of care of heart attack patients nationwide. However, because the current way in which hospitals are paid does not reward this quality improvement and provides limited financial incentive to adopt this program, all of the financial benefits of this quality improvement went to payers, rather than the hospital."
Dr. Khot will present his study on Monday, March 26 at 4:30 p.m. in Hall A.
Secondary Prevention Following Coronary Bypass Surgery: A National Randomized Trial (Presentation Number 412-9)
Continuous quality improvement (CQI) is a term used to describe a collaborative effort enabling health professionals to focus their energy and resources on the improvement of processes affecting quality of care. Cardiac surgeons have demonstrated success in improving perioperative care practices through CQI; this trial examined whether surgeons could act to influence long-term outcomes after surgical intervention.
Following coronary artery bypass grafting (CABG), evidence supports the use of secondary prevention with aspirin, beta-blockers, ACE inhibitors and lipid-lowering therapies, yet practice evaluation shows inconsistent initiation among eligible patients. In an effort to improve CABG efficacy and long-term patient outcomes, researchers from the Society of Thoracic Surgeons and the Duke Clinical Research Institute conducted a 24-month study to evaluate whether a low-intensity CQI intervention could speed surgeon adoption of this post-CABG secondary prevention practice.
In January 2004, 458 participating sites in the Society of Thoracic Surgeons’ Database were randomized to apply standard database feedback versus a CQI intervention, which included a call-to-action summarizing any secondary prevention activities, ongoing targeted site-specific feedback and other CQI tools. In addition, post-CABG patients were engaged by steering them to a Secondary Prevention Web site. The results were then analyzed to examine the primary outcome: use of any of the four medications among the 361,328 eligible CABG-only discharged patients.
Baseline treatment patterns were similar in both the control (n=234) and secondary prevention intervention (n=224) sites, and both groups showed an increase in individual medication prescription at discharge over 24 months. However, individual medication use was significantly increased in the intervention group, when compared to the control group, and a composite-use metric (all four medications) increased significantly from 67 to 78 percent over the 24-month intervention interval in the secondary prevention intervention group. Likewise, patient use of the Secondary Prevention Web site increased steadily over this same time interval.
"This continuous quality improvement program was successful in speeding adoption of post-CABG secondary prevention therapies, despite rapid generalized improvements in community care. More importantly, this significant adoption of best practice occurred on a national scale during this 24-month interval," said T. Bruce Ferguson, Jr., M.D., of the Brody School of Medicine at East Carolina University, and lead author on this study.
"This study represents the initial major attempt of the cardiac surgical community and its leading specialty society to influence long-term outcomes following a procedure through factors other than surgical technique. We found that surgeons can effectively incorporate secondary prevention practices into surgical care delivery. Their willingness to do so will undoubtedly improve the long-term outcomes and effectiveness of CABG, since these secondary prevention measures will influence the underlying progression of ischemic heart disease. As before with intraoperative factors, this CQI program has highlighted how we can change clinical practice, this time by addressing longitudinal, underlying disease issues, to better the quality of care for cardiovascular patients."
Dr. Ferguson will present this study on Monday, March 26 at 5:15 p.m. in Hall A.
The American College of Cardiology (www.acc.org) represents the majority of board certified cardiovascular physicians in the United States. Its mission is to advocate for quality cardiovascular care through education, research, promotion, development and application of standards and guidelines- and to influence health care policy. ACC.07 and the i2 Summit is the largest cardiovascular meeting, bringing together cardiologists and cardiovascular specialists to share the newest discoveries in treatment and prevention, while helping the ACC achieve its mission to address and improve issues in cardiovascular medicine.