Kim K. Birtcher

2016 ACC Expert Consensus Decision Pathway on the Role of Non-Statin Therapies for LDL-Cholesterol Lowering in the Management of Atherosclerotic Cardiovascular Disease Risk A Report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents

James L. Januzzi, Jr, MD, FACC, Chair Luis C. Afonso, MBBS, FACC Anthony Bavry, MD, FACC Brendan M. Everett, MD, FACC Jonathan Halperin, MD, FACC Adrian Hernandez, MD, FACC Hani Jneid, MD, FACC Dharam J. Kumbhani, MD, SM, FACC Eva M. Lonn, MD, FACC James K. Min, MD, FACC Pamela B. Morris

2016 ACC/AHA guideline focused update on duration of dual antiplatelet therapy in patients with coronary artery disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery

Further Evolution of the ACC/AHA Clinical Practice Guideline Recommendation Classification System: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

For 3 decades, the American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly developed clinical practice guidelines in an effort to align patient care with scientific evidence.l The “2015 ACC/AHA/HRS Guideline on the Management of Patients With Supraventricular Tachycardia”2 introduces the latest recommendation classification system Table 1, which has continued to evolve. The present brief commentary summarizes and explains the changes incorporated in the current scheme. More detailed reviews of the evolution of ACC/AHA guideline methodology have been published.1,3-5 View this table: Table 1. ACC/AHA Recommendation System: Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care* (Updated August 2015) Guideline recommendations are categorized by the Class of Recommendation (COR) and Level of Evidence (LOE). The COR reflects the magnitude of benefit over risk and corresponds to the strength of the recommendation. Class I recommendations are strong and indicate that the treatment, procedure, or intervention is useful and effective and should be performed or administered for most patients under most circumstances. Class II recommendations are weaker, denoting a lower degree of benefit in proportion to risk. Benefit is generally greater for Class Ila (moderate) recommendations and smaller for Class lib (weak) recommendations, for which benefit only marginally exceeds risk. A …

The Role of the Clinical Pharmacist in the Care of Patients With Cardiovascular Disease

Team-based cardiovascular care, including the use of clinical pharmacists, can efficiently deliver high-quality care. This Joint Council Perspectives paper from the Cardiovascular Team and Prevention Councils of the American College of Cardiology provides background information on the clinical pharmacists role, training, certification, and potential utilization in a variety of practice models. Selected systematic reviews and meta-analyses, highlighting the benefit of clinical pharmacy services, are summarized. Clinical pharmacists have a substantial effect in a wide variety of roles in inpatient and ambulatory settings, largely through optimization of drug use, avoidance of adverse drug events, and transitional care activities focusing on medication reconciliation and patient education. Expansion of clinical pharmacy services is often impeded by policy, legislation, and compensation barriers. Multidisciplinary organizations, including the American College of Cardiology, should support efforts to overcome these barriers, allowing pharmacists to deliver high-quality patient care to the full extent of their education and training.

Review of clinical practice guidelines for the management of LDL-related risk.

Managing risk related to low-density lipoprotein (LDL) is vital in therapy for patients at risk for atherosclerotic cardiovascular disease (ASCVD) events given its important etiologic role in atherogenesis. Despite decades of research showing reduction of ASCVD risk with multiple approaches to lowering of LDL cholesterol, there continue to be significant gaps in care with inadequate numbers of patients receiving standard of care lipid-lowering therapy. Confusion regarding implementation of the multiple published clinical practice guidelines has been identified as one contributor to suboptimal management of LDL-related risk. This review summarizes the current guidelines for reduction of LDL-related cardiovascular risk provided by a number of major professional societies, which have broad applicability to diverse populations worldwide. Statements have varied in the process and methodology of development of recommendations, the grading system for level and strength of evidence, the inclusion or exclusion of expert opinion, the suggested ASCVD risk assessment tool, the lipoproteins recommended for risk assessment, and the lipoprotein targets of therapy. The similarities and differences among important guidelines in the United States and internationally are discussed, with recommendations for future strategies to improve consistency in approaches to LDL-related ASCVD risk and to reduce gaps in implementation of evidence-based therapies.

Pharmacist-managed vaccination program increased influenza vaccination rates in cardiovascular patients enrolled in a secondary prevention lipid clinic.

Study Objectives. To determine whether a vaccination program in a pharmacist‐managed secondary prevention lipid clinic increased influenza immunization rates in a high‐risk population, and whether age or gender disparity existed among those vaccinated.

Performance achievement award program for Get With The Guidelines--Coronary Artery Disease is associated with global and sustained improvement in cardiac care for patients hospitalized with an acute myocardial infarction.

BACKGROUND Adherence to evidence-based guidelines for the treatment of coronary artery disease (CAD) is suboptimal. Our goal was to determine whether the performance achievement award program for Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) was associated with global and sustained adherence to evidence-based guidelines for acute myocardial infarction. METHODS Adherence to evidence-based guidelines was assessed in 170,061 hospitalized acute myocardial infarction patients from 418 US hospitals participating in GWTG-CAD from 2000 to 2008. Hospitals that received a performance achievement award by attaining 85% adherence with 6 GWTG performance measures for at least 12 consecutive months were compared with those that had enrolled in the GWTG-CAD and had not attained this level of adherence. The outcome measures were change in adherence for 6 GWTG performance measures, 9 GWTG quality measures, a composite score, and an all-or-none measure. Generalized estimating equations were used to provide valid inference accounting for the within site correlation. RESULTS Hospitals that maintained 85% adherence with GWTG performance measures for at least 12 consecutive months had a higher composite score (94.78 +/- 15.99% vs. 89.72 +/- 21.37, P < 0.0001) and an all-or-none measure (87.17% vs. 75.15%, P < 0.0001) compared with hospitals that had not yet attained this level of adherence. Hospital adherence with performance and quality measures generally improved over time. CONCLUSIONS In conclusion, the performance achievement award program for GWTG-CAD was associated with global and sustained adherence to evidence-based guidelines. Our data suggest that this tool is a useful component of a quality improvement initiative and should be considered for other similar programs.

A secondary prevention lipid clinic reaches low-density lipoprotein cholesterol goals more often than usual cardiology care with coronary heart disease

OBJECTIVE The objective of this study was to determine whether enrollment in a multidisciplinary secondary prevention lipid clinic (SPLC) for 3 or more years was associated with improved adherence to lipid guidelines as compared with usual care provided by cardiologists. METHODS Patients with documented coronary artery disease (CAD), enrolled in a SPLC, and followed for at least 3 years were identified by the use of a computer database. The comparison group included patients with CAD who received usual care from a cardiologist during the same time period. The percentage of patients achieving low-density lipoprotein cholesterol (LDL-C) goals at enrollment and after at least 3 years of follow-up was determined for both groups. The average total cholesterol, LDL-C, high-density lipoprotein cholesterol (HDL-C), and triglycerides were determined after at least 3 years of follow-up for both groups. RESULTS Patients enrolled in the SPLC reached the LDL-C goals more often than usual care cardiology patients (goal <100mg/dL: 81.9% vs. 72.8%, P < .001; optional goal <70 mg/dL: 41.9% vs. 28.6%, P < .001). The patients enrolled in the SPLC had lower average total cholesterol, triglycerides, and LDL-C and greater average HDL-C after 3 years. All the lipid parameters decreased for patients in usual cardiology care, but these changes were not statistically significant. CONCLUSIONS This multidisciplinary secondary prevention lipid clinic achieved the LDL-C goals (<100mg/dL and optional goal <70 mg/dL) more often than usual cardiology care for patients with CAD after 3 years of lipid management.

When compliance is an issue-how to enhance statin adherence and address adverse effects.

Cardiovascular disease is prevalent and costly. Interventions and therapies that reduce morbidity and mortality associated with cardiovascular disease could have an enormous impact on clinical and economic outcomes. Statins reduce atherosclerotic cardiovascular disease-related morbidity and mortality; however, adherence to statins is less than optimal. It is important for clinicians as well as health plan managers to be aware of the patient- and insurance plan-specific factors that have been shown to influence adherence. Perceived statin-related side effects may also decrease adherence. Statin-related myalgia may be difficult to distinguish from myalgia caused by other conditions, and statin therapy may be discontinued unnecessarily in patients who would otherwise benefit. It is imperative that clinicians work closely with patients to improve adherence to statin therapy and be knowledgable in managing potential statin-related side effects.

Measurement of Cholesterol

What is cholesterol, and what does it have to do with disease of the blood vessels and heart? Cholesterol is a fatty substance that is present in all the cells in your body. Cholesterol travels in your blood in particles called lipoproteins. Three of the common lipoproteins are low-density lipoproteins (LDL), high-density lipoproteins (HDL), and very low density lipoproteins (VLDL). Medical studies have shown that elevated levels of LDL cholesterol are associated with an increased risk of developing blockages in the coronary arteries, whereas elevated levels of HDL cholesterol reduce that risk. Thus, doctors sometimes refer to LDL as “bad cholesterol” and to HDL as “good cholesterol.” Cholesterol comes from 2 sources. Your body makes some cholesterol, and you also get cholesterol in foods that come from an animal (meat, milk, eggs, or anything made from these). Eating too much of these foods may increase the total amount of cholesterol in your body. Your body needs cholesterol to work properly. However, excess cholesterol can deposit in your arteries and promote formation of a deposit known as a plaque, which can grow larger over time; this process is called atherosclerosis. A piece of the plaque may break off and a blood clot may form on the …What is cholesterol, and what does it have to do with disease of the blood vessels and heart? Cholesterol is a fatty substance that is present in all the cells in your body. Cholesterol travels in your blood in particles called lipoproteins. Three of the common lipoproteins are low-density lipoproteins (LDL), high-density lipoproteins (HDL), and very low density lipoproteins (VLDL). Medical studies have shown that elevated levels of LDL cholesterol are associated with an increased risk of developing blockages in the coronary arteries, whereas elevated levels of HDL cholesterol reduce that risk. Thus, doctors sometimes refer to LDL as “bad cholesterol” and to HDL as “good cholesterol.” Cholesterol comes from 2 sources. Your body makes some cholesterol, and you also get cholesterol in foods that come from an animal (meat, milk, eggs, or anything made from these). Eating too much of these foods may increase the total amount of cholesterol in your body. Your body needs cholesterol to work properly. However, excess cholesterol can deposit in your arteries and promote formation of a deposit known as a plaque, which can grow larger over time; this process is called atherosclerosis. A piece of the plaque may break off and a blood clot may form on the …