Improved treatment of coronary heart disease by implementation of a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP)

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Abstract

Despite scientific evidence that secondary prevention medical therapies reduce mortality in patients with established coronary artery disease, these therapies continue to be underutilized in patients receiving conventional care. To address this issue, a Cardiac Hospital Atherosclerosis Management Program (CHAMP) focused on initiation of aspirin, cholesterol-lowering medication (hydroxymethylglutaryl coenzyme A [HMG CoA] reductase inhibitor titrated to achieve low-density lipoprotein [LDL] cholesterol ≤100 mg/dl), β blocker, and angiotensin-converting enzyme (ACE) inhibitor therapy in conjunction with diet and exercise counseling before hospital discharge in patients with established coronary artery disease. Treatment rates and clinical outcome were compared in patients discharged after myocardial infarction in the 2-year period before (1992 to 1993) and the 2-year period after (1994 to 1995) CHAMP was implemented. In the pre- and post-CHAMP patient groups, aspirin use at discharge improved from 68% to 92% (p <0.01), β blocker use improved from 12% to 62% (p <0.01), ACE inhibitor use increased from 6% to 58% (p <0.01), and statin use increased from 6% to 86% (p <0.01). This increased use of treatment persisted during subsequent follow-up. There was also a significant increase in patients achieving a LDL cholesterol ≤100 mg/dl (6% vs 58%, p <0.001) and a reduction in recurrent myocardial infarction and 1-year mortality. Compared with conventional guidelines and care, CHAMP was associated with a significant increase in use of medications that have been previously demonstrated to reduce mortality; more patients achieved an LDL cholesterol ≤100 mg/dl, and there were improved clinical outcomes in patients after hospitalization for acute myocardial infarction.

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Methods

The setting for this study was a university-associated teaching hospital. Full-time cardiology and medicine faculty as well as private clinical faculty serve as attending physicians supervising internal or family medicine housestaff. Before 1994, no specific treatment algorithms or management pathways were in place. Care was guided by individual physician decision and individual awareness and adherence to national clinical guidelines, such as the American College of Cardiology/American Heart

Results

From January 1992 to December 1995, 558 consecutive men and women were hospitalized for acute myocardial infarction and met the eligibility criteria, 256 in pre-CHAMP period of 1992 to 1993 and 302 in period after the implementation of CHAMP, 1994 to 1995. Demographic and clinical characteristics for the study groups are shown in Table 1. The 2 groups were similar with regard to a variety of baseline characteristics. Although the proportion of patients undergoing reperfusion therapy were

Discussion

This study demonstrates that CHAMP was an effective means to improve treatment utilization of clinical trial evidence-based therapies. It is also the first study to address the feasibility, safety, and impact on adherence of initiating lipid-lowering medications before discharge in patients hospitalized with acute myocardial infarction.

Prior studies have assessed the impact of programs to improve risk factor modification in patients with coronary artery disease. A physician-directed,

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This study was supported by the Ahmanson Foundation, Los Angeles, California. Manuscript received August 9, 2000; revised manuscript received and accepted October 18, 2000.

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