Cheryl A. Stoukides

Management of Hypercholesterolemia: Practice Patterns for Primary Care Providers and Cardiologists

This retrospective study, conducted as part of a private practice quality assurance process for patients with coronary artery disease (CAD), compares practice patterns in the LIFEHELP lipid clinic and non-lipid clinic settings at the Heart Institute of St. Petersburg. Quality assurance parameters included documentation of low-density lipoprotein (LDL) cholesterol, initiation of lipid-lowering therapy, and achievement of the Second National Cholesterol Education Program (NCEP II) goal for CAD patients of LDL cholesterol < or =100 mg/dL. A total of 934 patient charts with ICD-9 codes of 410-414 for ischemic heart disease were randomly selected and reviewed by a utilization review nurse. A higher level of documentation and treatment of elevated LDL cholesterol to NCEP II goal in CAD patients was found for those followed in the lipid clinic. Among non-lipid clinic physicians, cardiologists documented and treated elevated LDL cholesterol more frequently than primary care physicians. Women and the elderly subgroups received improved care in the lipid clinic setting. Screening activities and risk-factor management by cardiologists within a lipid clinic, therefore, demonstrated an improved standard of care that came closer to achieving national guidelines in the secondary prevention of CAD.

Pharmacotherapy for systolic dysfunction: a review of randomized clinical trials.

Chronic heart failure (HF) is a leading cause of morbidity and mortality in the United States, affecting >4 million people. The increasing prevalence of HF has placed an enormous burden on the US healthcare system. For many patients with cardiovascular disease, HF is the final common pathway. Treatment strategies for HF are aimed at preventing and delaying progression of the disease and ultimately improving survival. This article reviews recent clinical drug trials for HF, including angiotensin-converting enzyme (ACE) inhibitors, angiotensin II antagonists, vasodilators, beta-adrenergic blockers, positive inotropic agents, calcium antagonists, and antiarrhythmics. The benefits and shortcomings of these agents and the study designs are discussed. For patients with left ventricular (LV) systolic dysfunction, ACE inhibitors are the only agents that consistently improved survival and decreased the rate of HF progression. It is likely that beta-adrenergic blockers have the same effect. The syndrome of HF is complex with both peripheral and cardiac factors contributing to disease progression. The addition of a diuretic and/or digoxin is often needed to prevent worsening heart failure. Although an angiotensin II antagonist may also be beneficial in the treatment of HF, further studies are needed to clarify their precise role in the management of this condition. Calcium anatagonists, antiarrhythmics excluding amiodarone, and positive inotropes other than digoxin do not appear to prevent progression of HF nor improve survival. The most common cause of HF in the United States is related to coronary artery disease. Reduction of cardiac risk factors, such as smoking cessation, lowering serum cholesterol with diet and a lipid lowering agent, and blood pressure control, is likely to prevent the development or progression of HF.

Secondary prevention in a Cardiology group practice and hospital setting after a heart-care initiative

The American Heart Association (AHA) Consensus Panel Statement for Preventing Heart Attack and Death in Patients with Coronary Disease provides recommendations for the secondary prevention of heart disease in at-risk patients. Blackstone Cardiology Associates of Pawtucket, Rhode Island, undertook an initiative in their practice implementing secondary-prevention guidelines in patients with coronary artery disease. This retrospective study evaluates practice patterns for the management of hyperlipidemia for a cardiology group in an ambulatory and hospital setting after the institution of a physician-supervised, nurse-based disease management program. Practice patterns in patients with established coronary heart disease treated in a lipid center compared with non-lipid-center settings were evaluated. Parameters evaluated included documenting low-density lipoprotein (LDL) cholesterol, presence of lipid-lowering therapy, and achieving the National Cholesterol Education Program II (NCEP II) goal of LDL-cholesterol levels < or =100 mg/dL in patients with preexisting coronary artery disease. A total of 352 patients met inclusion criteria in the lipid-center setting and were compared with 289 non-lipid-center consecutively chosen patients. Age and gender differences were also evaluated. Inpatient medical records from a 254-bed Brown University-affiliated teaching hospital were also evaluated for lipid profile, achievement of NCEP II goal, and use of lipid-lowering medication on admission and discharge. The most recent LDL-cholesterol values of patients followed in the lipid-center and in the non-lipid-center setting of the Blackstone Cardiology Associates were compared. Blackstone Cardiology Associates consists of 4 cardiologists and 4 advanced-practice nurses. Achievement of LDL-cholesterol goal was higher in both the lipid-center and non-lipid-center settings compared with baseline. A smaller percentage of patients at goal in the lipid setting is likely due to referral bias resulting in patients with more difficult-to-manage mixed dyslipidemias and behavior-management issues ending up in the lipid center. There were no apparent sex differences at goal, and more elderly (age > or =65 years) achieved goal in the lipid clinic center. In the non-lipid-center setting, more males were at goal and had a lower mean LDL-cholesterol level.

Candesartan Cilexetil: An Angiotensin II Receptor Blocker

OBJECTIVE: To summarize and critique the medical literature on candesartan cilexetil, an angiotensin II receptor blocker (ARB). DATA SOURCES: MEDLINE searches (January 1966–January 1999) and manufacturer prescribing literature were used to identify articles on candesartan cilexetil. Bibliographies were also reviewed for germane articles. STUDY SELECTION: Study and review articles describing the chemistry, human pharmacology, pharmacodynamics, pharmacokinetics, placebo-controlled trials, comparative trials, and clinical application of candesartan cilexetil based on the published literature and premarketing clinical trials were reviewed. DATA EXTRACTION: All literature on the use of candesartan cilexetil for treating hypertension and congestive heart failure were included. DATA SYNTHESIS: ARBs are a new class of drugs with increasing use in treating hypertension. Studies are ongoing to determine the role of these agents in preventing remodeling after myocardial infarction and in patients with congestive heart failure. Candesartan cilexetil is among the newest drugs in the class that includes losartan, irbesartan, and valsartan. Candesartan cilexetil has more than 1000 times more affinity for the angiotensin II, type AT1 receptor ARBs, and the binding affinity and competitive angiotensin II receptor antagonism is stronger than that of losartan. Clinical studies in patients with hypertension have demonstrated that candesartan cilexetil, in doses of 4–16 mg, is more effective in reducing sitting diastolic blood pressure than are placebo and losartan 50 mg. Candesartan cilexetil has demonstrated reductions in blood pressure comparable to those of enalapril, with the rate of adverse events greater in the enalapril group. Dosage adjustments are not necessary in elderly patients or in patients with mild hepatic or renal dysfunction. In diabetic patients, blood glucose, hemoglobinA1c, and serum lipids are not affected. The clinical studies demonstrated that the adverse effect profile of candesartan cilexetil was similar to that of placebo and there were no dose-dependent adverse effects. CONCLUSIONS: Candesartan cilexetil provides an alternative antihypertensive therapy that is well tolerated and effective in reducing blood pressure in a wide range of patients. Due to its greater binding affinity to the angiotensin II receptor, candesartan cilexetil appears to have a longer antihypertensive effect than losartan. This may be advantageous in decreasing morbidity and mortality associated with hypertension, although further studies are required to validate this potential advantage.

Antithymocyte Immunoglobulin in Severe Aplastic Anemia and Bone Marrow Transplantation

OBJECTIVE: To review antithymocyte immunoglobulin (ATG) and its current role in the treatment of severe aplastic anemia (SAA), focusing on ATG in immunosuppressive therapy compared with bone marrow transplantation (BMT). DATA SOURCES: A MEDLINE search (1966 to 1996) of English-language literature and human subjects pertaining to ATG and BMT therapy in SAA was performed. Additional literature was obtained from reference lists of pertinent articles identified through the search. STUDY SELECTION AND DATA EXTRACTION: All articles were considered for possible inclusion in the review. Pertinent information, as judged by the authors, was selected for discussion. DATA SYNTHESIS: The hallmark of SAA is pancytopenia and bone marrow hypoplasia. Although the etiology in a majority of cases remains unknown, current data implicate an immune-mediated destruction of stem cells. ATG is a potent immunosuppressive agent and has emerged as an important therapy for patients with SAA. The exact mechanism of immunosuppressive action is not fully understood, although ATG appears to disrupt cell-mediated immune responses resulting in inhibition or altered T-cell function. Numerous trials have evaluated the use of ATG both as monotherapy and in combination with other immunosuppressive agents. Treatment with ATG in SAA has demonstrated a 40–70% response rate. Data suggest that intensive immunosuppressive therapy with ATG in combination with cyclosporine may provide the optimal immunosuppressive treatment. Questions still remain concerning complications and long-term survival of the patients. Although more than a 2-year follow-up shows a decline in mortality, a plateau in the survival curve was not achieved. BMT is a potential treatment for SAA. Although there is a high initial mortality due to treatment-related toxicities, successful marrow engraftment provides a cure for SAA. Many patients (75–90%) experience long-term survival after allogenic BMT. Age, donor availability, and severity of disease limit the number of eligible patients. CONCLUSIONS: Due to excellent results with BMT, it has become the therapy of choice for selected patients with SAA. For patients who are not eligible for BMT, intensive immunosuppressive therapy with ATG and cyclosporine is recommended. Further study to better understand the pathogenesis of SAA and prevent treatment-related complications is essential to provide the best care to all patients.

Resolution of tumor pain with EMLA cream.

A 69‐year‐old woman was admitted for control of intractable rectal pain caused by a 4‐cm malignant mass. She was treated successfully with EMLA (eutectic mixture of local anesthetics) cream applied every 8 hours and covered with a Xeroform dressing. Despite an increase in tumor size to 6 cm, her pain control was maintained with no local or systemic adverse effects. We believe topical EMLA may be effective in managing such lesions. Close patient monitoring is necessary, however, and long‐term, controlled studies must be conducted to determine its safety and efficacy in this setting.

Resolution of tumor pain with EMLA® Cream: A case report

A 69-year-oldwhite female with end-stage cob-rectal carcinoma was admittedto theHospice Careof RhodeIslandInpatient Unit for control of unretractable pain. The diagnosishadbeenmade threeyearspreviouslyfollowedby a colostomyandchemotherapy. Over thepastfourweeks,shehadbecome weakerandrequiredcareby herfour adult children assistedby a local home nursing agency.She developedsevererectalpainandwasadmittedto anacutecarefacility. She remainedtherefor 12 daystreated wtih escalatingdosesof continuous

Pharmacoeconomic Aspects and Formulary Considerations Related to Histamine2-Receptor Antagonists

Since the introduction of cimetidine in 1977, hospital expenditures for the histamine2-receptor antagonists have steadily increased, making them one of the most costly classes of therapeutic agents. As a result of cost considerations, we reviewed the available antiulcer agents in our hospital and evaluated the potential for therapeutic interchange within this group of agents. We found that by using famotidine as the principal agent in our hospital, drug cost savings of approximately

Guidelines for Prophylaxis of Cytomegalovirus Disease in Bone Marrow Transplant Patients

65 000 were realized. Additionally, avoiding the administration of approximately 13 000 parenteral doses with the selection of famotidine resulted in further reduction of drug administration costs. We conclude that the histamine2-receptor antagonists represent a cost-effective target for pharmacy cost-containment programs, without affecting patient therapeutic outcomes.

Impact of a Migraine Management Program on Improving Health Outcomes

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