The 2011 AHA/ACCF Guidelines for Secondary Prevention of Cardiovascular Disease: Words to Implement; Tools to Facilitate
Disclosure: Dr. Jessup has nothing to disclose.
Pub Date: Thursday, Nov. 3, 2011
Author: Mariell Jessup, M,D,, FAHA, FACC
Affiliation: University of Pennsylvania School of Medicine
Penn Heart and Vascular Center
Citation: Smith SC Jr, Benjamin EJ, Bonow RO, Braun LT, Creager MA, Franklin BA, Gibbons RJ, Grundy SM, Hiratzka LF, Jones DW, Lloyd-Jones DM, Minissian M, Mosca L, Peterson ED, Sacco RL, Spertus J, Stein JH, Taubert KA. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation. 2011: published online before print November 3, 2011, 10.1161/CIR.0b013e318235eb4d.
The 2011 update of the guidelines for secondary prevention and risk reduction therapy for patients with established cardiovascular disease is the culmination of five years of additional efforts since a similar document was published in 20061 to establish the “merits of intensive risk-reduction therapies” to improve outcomes and enhance quality of life2. The writing committee has reviewed numerous related cardiovascular guidelines and prevention studies to develop these evidence-based recommendations, which cover smoking cessation, blood pressure and lipid control, physical activity, weight and depression management, and specific pharmacologic therapies. Undoubtedly, countless hours were devoted to the careful construction of the recommendations, in the hope that the significant morbidity and mortality from cardiovascular complications currently documented can be partially assuaged.3
It is interesting to reflect on some of the common language used to craft the recommendations, as a guide to the next steps for implementation of this publication. First, the guidelines are patient focused, proposing clinicians to ask, counsel, and encourage the individuals in their examining rooms. This necessitates a conversation about lifestyle, and mood, along with the routine questions about angina or claudication. Note, too, that the recommendations require the clinician to have discrete data documented in the chart, as part of the goal setting for the individual patient. Ongoing data that needs to be collected and actively utilized include body mass index (BMI), waist circumference, left ventricular ejection fraction, LDL cholesterol, hemoglobin A1C, and influenza vaccination. Finally, the appropriate institution of pharmacotherapies demands an up-to-date list of medical problems for each patient, including past coronary surgery or stent, diabetes, renal function, and results of carotid screening. Two important concepts are also highlighted in the current guidelines: the aging of our population with a resultant increase in cardiovascular disease, and the evidence that life-saving therapies are under-utilized. Clearly, the challenge now is to develop systems of care that incorporate discrete patient data and problem lists with concurrent therapy in the context of guideline-based management, all without sacrificing the important therapeutic conversation between a patient and clinician.
As with any other complex problem involving many variables, computer based systems may be a solution.4 There has been a major focus on the use of electronic medical records (EMR) to facilitate optimal care for other disease states, and the technology is ideally suited for the secondary prevention of atherosclerotic vascular disease as well.5-6 Increasingly, cardiology and general medicine practices are leveraging the power of the EMR to provide clinical decision support. Automated reminder systems, guidelines and algorithms for stepped care are easy to configure in most EMRs, but are only as good as the discrete data and problem lists that are documented. All of which circles back to the role of the clinician: to ask, counsel and encourage their patients about lifestyle and medications, prompted by an EMR, and empowered by the evidence of our newest guidelines.
- Smith SC, Jr., Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. Circulation 2006;113:2363-72.
- Smith SC, Benjamin EJ, Bonow RO, et al. AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease: 2011 Update. A Guideline from the American Heart Association and American College of Cardiology Foundation. Circulation 2011;124:00-000.
- Roger VL, Go AS, Lloyd-Jones DM, et al. Heart disease and stroke statistics--2011 update: a report from the American Heart Association. Circulation 2011;123:e18-e209.
- Blumenthal D, Tavenner M. The "meaningful use" regulation for electronic health records. N Engl J Med 2010;363:501-4.
- Weintraub WS, Karlsberg RP, Tcheng JE, et al. ACCF/AHA 2011 key data elements and definitions of a base cardiovascular vocabulary for electronic health records: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards. Circulation 2011;124:103-23.
- Sittig DF, Wright A, Osheroff JA, et al. Grand challenges in clinical decision support. J Biomed Inform 2008;41:387-92.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association --