Cardiology Update 2

A collection of interview-based cardiology articles by leading experts.

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Cardiology Update Read some of our top articles on atrial fibrillation, heart failure, statins, and more.

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Table of Contents 14

aking the Link Between CKD M & Atrial Fibrillation — Elsayed Z. Soliman, MD, MSc, MS

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I ncreasing Awareness of Atrial Fibrillation — Nassir F. Marrouche, MD

10 I mproving Health in Patients With Heart Failure — Barbara Riegel, DNSc, RN, FAHA

114 E mpowering Patients to Reduce Their CVD Risk — Dariush Mozaffarian, MD, DrPH

118 Making the Case for Statins — Lee H. Schwamm, MD

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March 15, 2011 Click here to view this article online.

Making the Link Between

CKD & Atrial Fibrillation

Elsayed Z. Soliman, MD, MSc, MS Director, Epidemiological Cardiology Research Center (EPICARE) Assistant Professor of Epidemiology and Cardiology Wake Forest University Baptist Medical Center

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revious studies have shown that patients with advanced chronic kidney disease (CKD), including those on dialysis, have an increased risk for atrial fibrillation (AF). There are limited data, however, on the prevalence and risk factors of AF in less severe CKD, which is substantially more common than end-stage renal disease. Over 25 million adults in the United States have CKD; most of them are in the early stages of CKD. Understanding the prevalence and risk factors of AF in these patients has important public health, epidemiological, and clinical implications.

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Important New Data New research suggests that patients with CKD, even in its early stages, have similar rates of AF. In a study published in the June 2010 American Heart Journal, my colleagues and I at Wake Forest University attempted to better define the link between CKD and AF using data from the Chronic Renal Insufficiency Cohort (CRIC), a study sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases, which is part of the NIH. We found that nearly 20% of study participants with early stages of CKD had evidence of AF, a rate similar to what has been reported among patients with end-stage renal disease. This rate is also two to three times the AF rates reported in the general population using similar AF detection methods.

Another key finding from our investigation was that the risk factors for AF in patients with CKD did not appear to be the same as those seen in the general population. Contrary to the general population, the

Clinicians must make efforts to detect AF as early as possible in individuals with CKD so as to reduce their risk of AF complications such as stroke.

following were not significant risk factors for AF in CKD patients: • Race/ethnicity • Hypertension • Diabetes

The high rate of AF seen in patients with early stages of CKD suggests that the processes that influence the development of AF occur early in the course of CKD. The importance of learning about these processes comes in utilizing strategies for preventing AF.

Wanted: More Research

• Obesity

Assessing the Impact Our results from the CRIC study exposed a new population of potentially millions of patients who were previously thought of as being at low risk for AF. This means that clinicians must make efforts to detect AF as early as possible in individuals with CKD so as to reduce their risk of AF complications such as stroke.

Based on the results of our study, it is clear that AF is a common problem in patients with CKD, regardless of the severity of kidney disease. Detecting AF early is critical, but it would also be helpful to understand how aggressive physicians should be with treatment so that outcomes can improve. It would behoove us to develop a separate set of AF predictors that are specifically designed for patients with CKD. This may ultimately result in effective, earlier detection and treatment for this serious risk factor for stroke, and may decrease mortality rates in those with CKD.

Elsayed Z. Soliman, MD, MSc, MS, has indicated to Physician’s Weekly that he has no financial disclosures to report.

References Soliman EZ, Prineas RJ, Go AS, et al. Chronic kidney disease and prevalent atrial fibrillation: the chronic renal insufficiency cohort (CRIC).

Am Heart J. 2010;159:1102-1107. Abstract available at: www.ahjonline.com/article/S0002-8703(10)00253-X/abstract.

Chamberlain AM, Agarwal SK, Ambrose M, Folsom AR, Soliman EZ, Alonso A. Metabolic syndrome and incidence of atrial fibrillation among blacks and whites in the Atherosclerosis Risk in Communities (ARIC) Study. Am Heart J. 2010;159:850-856.

Meschia JF, Merrill P, Soliman EZ, et al. Racial disparities in awareness and treatment of atrial fibrillation: the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. Stroke. 2010;41:581-587.

Horio T, Iwashima Y, Kamide K, et al. Chronic kidney disease as an independent risk factor for new-onset atrial fibrillation in hypertensive patients.

J Hypertens. 2010;28:1738-1744.

Ananthapanyasut W, Napan S, Rudolph EH, et al. Prevalence of atrial fibrillation and its predictors in nondialysis patients with chronic kidney disease.

Clin J Am Soc Nephrol. 2010;5:173-181.

Aronow WS. Acute and chronic management of atrial fibrillation in patients with late-stage CKD. Am J Kidney Dis. 2009;53:701-710.

Reinecke H, Brand E, Mesters R, et al. Dilemmas in the management of atrial fibrillation in chronic kidney disease. J Am Soc Nephrol. 2009;20:705-711.

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February 14, 2011 Click here to view this article online.

Increasing Awareness of

Atrial Fibrillation A new educational program urges clinicians to communicate with their patients about their awareness of atrial fibrillation, a condition linked to an increased risk of stroke.

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Nassir F. Marrouche, MD Executive Director, Comprehensive Arrhythmia Research & Management Center Director, Electrophysiology Laboratories Associate Professor of Medicine University of Utah

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new educational program urges clinicians to communicate with their patients about their awareness of atrial fibrillation, a condition linked to increased risk of stroke.

Research has shown that atrial fibrillation (AFib) is one of the most common sustained heart rhythm abnormalities, affecting an estimated 2.3 million Americans, but other investigations suggest that the condition may affect millions more. “Atrial fibrillation is a potentially serious condition,” says Nassir F. Marrouche, MD. “The irregular heartbeat associated with AFib can cause blood to pool in the atria, which can result in the formation of clots. These blood clots can travel from the heart to the brain, where they can lead to stroke.”

According to current estimates, AFib increases the risk of stroke nearly five-fold. About 15% of all strokes in the United States are associated with AFib. Strokes that are associated with AFib are

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Efforts are needed to empower patients with AFib to be proactive in their efforts to reduce their stroke risk. about twice as likely to be fatal or severely disabling as non–AFib-related strokes. In the United States, studies have predicted that as many as 5.6 million American adults will have AFib by 2050. One of the largest demographics to be affected by AFib includes elderly individuals. It has been estimated that 3% to 5% of elderly Americans have AFib, but that number may be larger because symptoms often go unrecognized by patients and physicians alike.

Spotting AF Symptoms One of the aspects of AFib that makes it difficult to manage is that the condition is not always accompanied with symptoms. Published studies have shown that several symptoms may be attributable to AFib, including racing or irregular heartbeat, fluttering in the chest, heart palpitations, and shortness of breath.

Other symptoms of AFib include chest pain, fatigue when exercising, sweating, and weakness, dizziness, or faintness. “It’s challenging for physicians to identify AFib because the symptom checklist is often lumped into the diagnosis of other cardiac issues, such as heart disease, hypertension, ischemia, or heart failure,” explains Dr. Marrouche. “Age has become a more prominent risk factor in recent years based on scientific data, but there are still many unknowns about the causes and manifestations of AFib.”

Survey Sheds Light on Awareness Issue Boehringer Ingelheim Pharmaceuticals, Inc., the National Stroke Association, and StopAfib.org

Table 1

recently collaborated to launch a new national education program to improve awareness of AFib and its increased risk of stroke. The program, “Facing AFib™,” is a multi-year initiative designed to educate Americans about AFib and encourage those with it to take steps to help reduce their stroke risk. The program also aims to improve the communication between patients and physicians in an effort to address gaps that were identified through AFib STROKE (Atrial Fibrillation Survey To Reveal Opinions, Knowledge and Education gaps). This survey was conducted in the United States among 507 patients and 517 healthcare providers, including 150 cardiologists, 150 primary care physicians, and 217 nurse practitioners.

“A key finding from AFib STROKE was that 40% of patients with AFib do not feel that they’re at personal risk for stroke,” says Dr. Marrouche (Table 1). “This is a poor reflection on patient education efforts because physicians aren’t driving home the message that AFib is a serious condition with potentially lethal consequences. Many patients are leaving their hospitals or doctor’s offices believing that they aren’t at any real risk for stroke despite evidence to the contrary. For clinicians, this should be a call to action to arm patients and caregivers with important information about AFib and stroke. Efforts are needed to empower patients with AFib to be proactive in their efforts to reduce their stroke risk.”

Gaps Persist in Patient-Healthcare Practitioner Communication Percent Recall Conversation Taking Place

Topics Discussed at Diagnosis

Cardiologists

Primary Care Physicians

Nurse Practitioners

Patients

Treatment options for stroke prevention and their risks and benefits

92%

92%

75%

41%

Link between atrial fibrillation (AFib) and increased risk of stroke

90%

89%

75%

49%

Patient’s personal risk of stroke associated with AFib

81%

64%

53%

45%

Source: AFib STROKE Survey Results. Available at: http://afibstrokesurvey.com/userfiles/file/AFIb-STROKE-Survey-Fact%20Sheet.pdf.

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Increased Education is Warranted Results on general awareness and attitudes from AFib STROKE have also been released. The survey, which was led by a steering committee of five medical thought leaders and advocates dedicated to improving education in the AFib community, revealed several alarming findings (Table 2). For example, only 45% of patients with AFib recalled discussing their personal AFib-related stroke risk with their healthcare provider when they were first diagnosed. Less than 35% of patients took the initiative to ask their providers about their personal stroke risk, and about two-thirds of patients (67%) reported that they would like more information about AFib. “These survey findings demonstrate that there’s a crucial need for more education and tools that will help patients and their healthcare providers more effectively communicate about AFib-related stroke risk,” Dr. Marrouche says. “The Facing AFib initiative can serve as an important aid for patients because it provides the valuable information they want and the resources they need to help them translate knowledge into action.” Physicians and other healthcare providers can guide their patients to the program website, www.FacingAFib.com . It offers valuable resources, including an interactive risk assessment tool and a personalized doctor discussion guide. The website also provides access to a free book with information on AFib and the opportunity to register for program updates.

Assessing Attitudes & Awareness on AFib

Table 2

The AFib STROKE (Atrial Fibrillation Survey to Reveal Opinions, Knowledge and Education Gaps) survey was conducted in patients and healthcare providers to assess awareness and attitudes toward atrial fibrillation (AFib) and its related stroke risk and treatment.

Among patients with AFib: • 56% said the condition has had a negative impact on their lives.

• 55% said AFib has impacted their ability to participate in physical activities.

• 43% said their most feared complication of their condition was stroke.

• 17% said their most feared complication of their condition was death.

• 83% of patients knew AFib is a risk factor for stroke.

• 33% of patients said stroke prevention is the most important goal of AFib treatment.

• 86% of AFib patients wished there was greater public awareness of AFib. Among healthcare professionals: • 47%-50% knew that strokes associated with AFib are twice as deadly and twice as disabling as non–AFib-related strokes.

• 61%-68% felt that increased public awareness about AFib and stroke would help them talk to patients more effectively.

Source: AFib STROKE Survey Results. Available at: http://afibstrokesurvey.com/ userfiles/file/AFIb-STROKE-Survey-Fact%20Sheet.pdf.

Nassir F. Marrouche, MD, has indicated to Physician’s Weekly that he has received grants for clinical research from Siemens and SurgiVision. He has served as an advisor or consultant for sanofi-aventis and BoehringerIngelheim, and has served as a speaker or member of a speaker’s bureau for Biosense Webster, Inc.

References For information about the AFib STROKE program, go to http://afibstrokesurvey.com/afib-stroke-survey-fact-sheet/.

Go AS, Hylek EM, Phillips KA, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001;285:2370-2375.

Singer DE, Go AS. Antithrombotic therapy in atrial fibrillation. Clin Geriatr Med. 2001;17:131-147.

Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991;22:983-938.

Lin HJ, Wolf PA, Kelly-Hayes M, et al. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996;27:1760-1764.

Dulli DA, Stanko H, Levine RL. Atrial fibrillation is associated with severe acute ischemic stroke. Neuroepidemiology. 2003;22:118-123.

Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.

Ann Intern Med. 2007;146:857-867.

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February 7, 2011 Click here to view this article online.

Improving Health in

Patients With Heart Failure

A scientific statement from the American Heart Association defines self-care behaviors for managing heart failure. It identifies patient, physician, and healthcare system barriers, and offers interventions to promote self-care.

Barbara Riegel, DNSc, RN, FAHA Professor & Interim Chair Family and Community Health Division University of Pennsylvania

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scientific statement from the American Heart Association defines self-care behaviors for managing heart failure. It identifies patient, physician, and healthcare system barriers and offers interventions to promote self-care.

The American Heart Association (AHA) recently issued a scientific statement for the promotion of selfcare in people with heart failure (HF). The statement, published in the September 22, 2009 issue of 10

Circulation, highlights concepts and evidence that are important to the understanding and promotion of selfcare in this patient group as well as others. “In recent years, physicians and professional associations have better recognized the critical need for and benefit from self-care among patients,” explains Barbara Riegel, DNSc, RN, FAHA, who chaired the committee that generated the scientific statement. “Tremendous advances have been made in medical therapies for HF, but clinicians often have difficulty with assisting HF patients in the integration of the daily self-care behaviors they need. These behaviors, however, are important to offsetting the burden of HF.” The AHA scientific statement aims to bring attention to the importance of self-care for HF and offers recommendations for physicians on how to promote self-care. While targeted to HF patients and the providers who manage them, the statement can

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also be applicable to primary care physicians. “HF is typically the final common pathway for other chronic conditions, such as hypertension and coronary artery disease,” says Dr. Riegel. “Anyone caring for a patient with diabetes, high blood pressure, elevated cholesterol, etc, can use the principles in this statement to promote self-care.”

Recommended Self-Care Behaviors

Table 1

Patients with HF should be instructed to participate in the following self-care behaviors:

Self-care is defined in the AHA statement as a decision-making process that patients use to maintain their health through ongoing practices and healthy behaviors (Table 1). “Physicians should advise HF patients on the importance of these behaviors,” Dr. Riegel explains. “Patients and their caregivers are responsible for self-care. Physicians should engage patients and their caregivers to provide additional support and promote self-care. Encouragement by family members may lead to further improvements in self-care and enhance outcomes.”

• Take medications as prescribed.

Self-care also includes active monitoring of symptoms and responding to them as needed. “Keeping lines of communication open between HF patients and providers is essential,” says Dr. Riegel. “Providers can educate patients on how to monitor their symptoms and when to inform them of any changes.”

• Talk to providers or pharmacists about herbal medicines.

Spot Potential Barriers

• Restrict dietary sodium.

- Maintain a daily diet with 2-4 g of sodium.

• Visit healthcare providers at regular intervals.

• Maintain current immunizations.

- Annual vaccination against influenza.

- Older adults (older than 65) should be immunized against Streptococcus pneumoniae unless contraindicated.

• Cease all tobacco use and avoid secondhand smoke.

• Avoid other recreational toxins, especially cocaine.

• Restrict alcohol intake.

- Limit intake: 2 drinks/day for men and 1 drink/day for women.

• Achieve and maintain physical activity.

- Routinely exercise at levels based on prescriptions derived from exercise testing results.

• Monitor body weight and notify providers of unexpected declines/increases.

- Weight loss should be advised when BMI exceeds 40 kg/m2.

• Recognize signs/symptoms of worsening HF (eg, shortness of breath, swelling, or fatigue).

• Inform providers of any sleep disturbances or daytime sleepiness.

• Recognize and seek treatment for emotional distress, especially depression and anxiety.

• Practice preventive behaviors (eg, routine hand washing and daily dental hygiene).

• If diabetic, achieve diabetes treatment goals.

Abbreviations: HF, heart failure.

Source: Adapted from: Riegel B, et al. Circulation. 2009;120:1141-1163.

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Defining Self-Care

There are several factors that interfere with self-care management for HF, including patient barriers, healthcare system barriers, and provider barriers.

When considering patient barriers, it should be noted that nearly all individuals with HF have other illnesses to consider (eg, hypertension, coronary artery disease, diabetes, renal insufficiency, and arthritis). The presence of comorbidities contributes to difficulties in self-care.

There may be challenges with taking medications, adhering to a healthy diet, and monitoring symptoms.

Depression and anxiety are also common among HF patients and adversely affect self-care practices. Dr. Riegel says age can also be associated with poor selfcare. “Younger patients tend to be less aware of the effects of their behavior on their HF. It’s hard to get younger patients’ attention about the need to practice self-care; they feel invincible,” she says. Additionally, about 25% to 50% of HF patients have cognitive impairment, and many also have sleep disturbances.

Both conditions can interfere with patients’ ability to focus on health and practice self-care. Lastly, the health literacy level of HF patients is often low.

A key problem in HF is that most healthcare systems fail to promote self-care for these patients.

In particular, self-care education in the inpatient and outpatient settings is lacking. The absence of a common medical record and the existence of multiple providers complicate processes even further. Dr. Riegel says “many healthcare systems operate in silos when it

comes to treating HF. It’s critical that they collaborate as providers to treat HF patients more successfully and promote greater adherence to self-care.” She adds that clinical guidelines should be updated to reflect the importance of and evidence for promoting self-care skills among patients with HF. “Policy makers should reconsider reimbursement for patient education, counseling, and coordination of care as these are essential to effective self-care.” Furthermore, the AHA scientific statement recommends that medical school curricula include physician education on how to instruct patients in self-care. Consistent and accurate information should be communicated from providers.”

Recommendations for Clinicians The AHA scientific statement offers specific recommendations for healthcare providers, based upon expert opinion (Table 2). Among these, routine, repeated, and ongoing assessment of health literacy level, comorbidities, depression/anxiety, and sleep disorders is critical. “Healthcare providers should approach each patient with the suspicion that they’re not performing good self-care,” says Dr. Riegel. “Clinicians should expect that they may have circumstances that impair their ability to succeed at self-care, such as daytime sleepiness, cognitive impairment, or depression.

Fortunately, clinicians can make a difference by taking time to educate and encourage HF patients. There are also a few simple screening tools to help identify HF patients that are at high-risk for poor self-care. The key is to utilize these tools at every opportunity in an effort to reduce the burden of HF.” Barbara Riegel, DNSc, RN, FAHA, has indicated to Physician’s Weekly that she has received research support from the National Institutes of Health, the American Heart Association, and the Kynett Foundation.

Table 2

Methods to Promote Self-Care

The following strategies can be used to promote self-care among patients with heart failure: • Provide structured and individually reinforced education during all clinical encounters. Consider literacy level and cultural background.

• Teach skills (eg, how to choose a low-sodium diet, and how to monitor and evaluate symptoms when they occur) rather than simply providing information.

• Assess for use of OTC medications and herbal remedies; involve a pharmacist if necessary to determine whether drug interactions are a problem.

• Discourage NSAID use and help patients identify alternatives.

• Treat comorbid conditions aggressively.

• Individualize treatment on the basis of prognosis and quality of life.

• Screen routinely for depression and anxiety, and treat immediately.

• Screen routinely for barriers to self-care (eg, inability to afford medicines) so that solutions can be developed.

• Encourage dental hygiene; inquire about routine flossing and dental cleaning.

• Ask about sleep quality. Refer patients who report poor sleep, who are obese, and whose bed partner reports snoring to screening for sleep-disordered breathing.

Strongly encourage use of continuous positive airway pressure in patients with sleep-disordered breathing.

• Eliminate medications with daytime sleepiness as a side effect when possible.

• Assess cognitive abilities on an ongoing, routine basis; use an approach that is sensitive to known defects in memory, executive function, and processing speed.

• Include family and friends in education and counseling activities.

• Refer patients to social workers if social isolation is a problem.

• Consider ways to create more seamless systems from inpatient to outpatient settings.

Source: Adapted from: Riegel B, et al. Circulation. 2009;120:1141-1163.

References Riegel B, Moser DK, Anker SD, et al; on behalf of the American Heart Association Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Nutrition, Physical Activity, and Metabolism, and Interdisciplinary Council on Quality of Care and Outcomes Research. State of the Science.

Promoting self-care in persons with heart failure. A scientific statement from the American Heart Association. Circulation. 2009;120:1141-1163.

Available at: http://circ.ahajournals.org/cgi/content/full/120/12/1141 Westlake C, Dracup K, Fonarow G, Hamilton M. Depression in patients with heart failure. J Card Fail. 2005;11:30-35.

Zambroski CH, Moser DK, Bhat G, Ziegler C. Impact of symptom prevalence and symptom burden on quality of life in patients with heart failure.

Eur J Cardiovasc Nurs. 2005;4:198-206.

Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patients with chronic heart failure. Circulation.

2005;111:179-185.

Wu JR, Moser DK, De Jong MJ, et al. Defining an evidence-based cutpoint for medication adherence in heart failure. Am Heart J. 2009;157:285-291.

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January 25, 2011 Click here to view this article online.

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Empowering Patients to Reduce Their

CVD Risk

A new scientific statement identifies multiple evidence-based strategies that healthcare providers can use to help patients embrace the diet and physical activity changes that lower their risk for cardiovascular diseases, including setting specific focused goals, feedback and self-monitoring, and extended patient follow-up.

Dariush Mozaffarian, MD, DrPH Assistant Professor of Medicine Department of Epidemiology Harvard Medical School Associate Physician Brigham and Women’s Hospital

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ccording to the American Heart Association (AHA), nearly 80 million adults have at least one type of cardiovascular disease (CVD), and it is the most deadly disease in the United States. Studies indicate that if CVD were completely eradicated, life expectancy could increase by nearly 7 years. In the July 27, 2010 issue of Circulation, the AHA released a scientific statement on individual-level interventions that are designed to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. “Individual-level interventions that target dietary patterns, weight reduction, and new physical activity habits often result in impressive rates

of initial behavior changes,” says Dariush Mozaffarian, MD, DrPH, who co-chaired the panel that developed the scientific statement. “Unfortunately, many of these behavioral changes are often not maintained for the long term.”

The purpose of the scientific statement is to provide evidence-based recommendations on individual-level strategies—for example, in the healthcare setting—for implementing physical activity and dietary interventions in all adults, regardless of racial or ethnic background and socioeconomic demographic. The most efficacious and effective strategies were summarized (Table), and guidelines were provided to translate these strategies into practice. The AHA committee reviewed 74 studies conducted among U.S. adults between 1997 and 2007. The studies measured the effects of behavioral change on blood pressure and cholesterol levels, physical activity and aerobic fitness, and diet.

“There has been an explosion of data emerging on behavioral research and science over the past decade,” Dr. Mozaffarian notes, “and the time was right to visit www.physiciansweekly.com

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systematically review the evidence base for behavioral strategies to improve physical activity and diet to reduce the burden of CVD.”

Cognitive Behavior Strategies Are Key According to the AHA scientific statement, cognitivebehavioral strategies are an essential com­ ponent of behavior change interventions. “These strategies focus on changing how individuals think about themselves, their behaviors, and surrounding circumstances,” explains Dr. Mozaffarian. “They also focus on how to

Summarizing Strategies to Promote Dietary & Physical Activity Changes Table

The following are recommendations the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing: Cognitive-Behavioral Strategies for Promoting Behavior Change Class I • Design interventions to target dietary and physical activity (PA) behaviors with specific, proximal goals.

• Provide feedback on progress toward goals.

• Provide strategies for self-monitoring.

• Establish a plan for frequency and duration of follow-up contacts in accordance with individual needs to assess and reinforce progress toward goal achievement.

• Utilize motivational interviewing strategies, particularly when an individual is resistant or ambivalent about dietary and PA behavior change.

• P rovide for direct or peer-based long-term support and follow-up to offset the common occurrence of declining adherence that typically begins at 4-6 months in most behavior change programs.

• Incorporate strategies to build self-efficacy into the intervention.

• Use a combination of ≥2 of the above strategies (eg, goal setting, feedback, self-monitoring, follow-up, motivational interviewing, self-efficacy) in an intervention.

Class II • Use incentives, modeling, and problem solving strategies.

modify patients’ lifestyle.” Data indicate that using at least two strategies—and preferably more—can yield substantially more favorable outcomes than using fewer cognitive behavioral strategies. The AHA scientific statement provides several Class I recommendations, which are supported with the strongest level of evidence, that Dr. Mozaffarian says should be recognized and utilized by clinicians. “For example,” he says, “setting targeted short-term goals at the outset is important to achieving desired behavior changes. Under most circumstances, setting such specific goals leads to greater

Intervention Processes and/or Delivery Strategies Class I • Use individual- or group-based strategies.

• Use individual-oriented sessions to assess where the individual is in relation to behavior change, to jointly identify the goals for risk reduction or improved cardiovascular health, and to develop a personalized plan to achieve it.

• Use group sessions with cognitive-behavioral strategies to teach skills to modify the diet and develop a PA program, to provide role modeling and positive observational learning, and to maximize the benefits of peer support and group problem solving.

• For appropriate target populations, use internetand computer-based programs to target dietary and PA change; evidence is less for targeting PA alone; adding a form of e-counseling improves outcomes.

Class IIa • Use individualized rather than non-individualized print- or media-only delivery strategies.

Addressing Cultural & Social Context Variables Class IIa • Utilize church, community, work, or clinic settings for delivery of interventions.

• Use a multiple-component delivery strategy that includes a group component rather than individualonly or group-only approaches.

• Use culturally adapted strategies, including use of peer or lay health advisors to increase trust; tailor health messages and counseling strategies to be sensitive to the cultural beliefs, values, language, literacy, and customs of the target population.

• Use problem solving to address barriers to PA and dietary change, such as lack of access to affordable healthier foods, lack of resources for PA, transportation barriers, and poor local safety.

Source: Adapted from: Artinian NT, et al. Circulation. 2010;122:406-441.

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behavior change when compared with too many goals or vague goals.” The use of goals is more successful when they’re specific in outcome, proximal in terms of attainment, and realistic in terms of the individual’s capability. Goals that focus on behavior rather than a physiological target are also preferable because patients can control their behaviors more directly.

After goals are set, consistent self-monitoring and extended follow-up and counseling with healthcare providers are recommended to help pa­tients achieve lifestyle changes to reduce their CVD risk. Simple selfmonitoring—such as recording diet or physical activity changes in a diary—is an established strategy to maximize lifestyle changes. Diet and exercise programs that incorporate scheduled follow-up sessions as a core component are also generally more effective. Healthcare provider or electronic feedback is also important as it helps patients learn new dietary or exercise behavioral skills by providing an external measuring stick against which to assess their progress. According to published data, motivational interviewing—a directive, individual-centered counseling style for eliciting behavioral changes—can also be beneficial when patients are ambivalent about behavior change.

Process & Delivery Strategies Studies that assessed interventions such as pro­viding

educational materials, counseling sessions, and followup monitoring have been variable with regard to findings, but most report positive results. “Media messages, printed materials, and other non-individualized educational strategies may be useful to encourage physical activity and dietary changes,” says Dr. Mozafarrian, “but these materials may not encourage patients to maintain these behavioral changes over a lifetime.

Other approaches can also benefit patients, such as group-based, individual-based, computer/technologybased, and multi-component interventions. How­ever, clinicians need to determine which of these additional interventions make the most sense for each individual patient.”

Healthcare System Changes Needed The AHA scientific statement notes that current healthcare policies should be modified to encourage use of behavioral interventions for physical activity and diet changes. Dr. Mozaffarian says “the evidence-base for behavior change strategies is now clear, so the remaining challenge is the translation of this knowledge into action. To help with this translation, it’s important to 1) disseminate this information, 2) educate clinicians through training, 3) facilitate processes for physicians with tools, 4) change reimbursement plans, and 5) develop quality guidelines and metrics to incorporate diet and exercise behavior changes.”

Dariush Mozaffarian, MD, DrPH, has indicated to Physician’s Weekly that he has received research grants from the NHLBI and NIEHS; the Searle Scholar Award from the Searle Funds at The Chicago Community Trust; the Genes and Environment Initiative at the Harvard School of Public Health; the Gates Foundation/World Health Organization Global Burden of Diseases, Injuries, and Risk Factors Study; and GlaxoSmithKline, Sigma Tau, and Pronova for an investigator-initiated trial of fish oil to prevent post-surgical arrhythmia. He has received small royalty payments (<1k/year) for a chapter on fish oil in UpToDate and modest honoraria for speaking at scientific conferences and reviewing on topics related to diet and cardiovascular disease, including from the FDA, United Nations, WHO, Institute of Food Technologists, American Oil Chemists Society, National Lipid Association, International Life Sciences Institute, Aramark, American Diabetes Association, American Dietetic Association, and several universities. He has no ownership, patents, stocks, advisory board membership, nor speaking board membership. For more information on this article, including references, visit www.physiciansweekly.com.

References Artinian NT, Fletcher GF, Mozaffarian D, et al; on behalf of the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing.

Interventions to Promote Physical Activity and Dietary Lifestyle Changes for Cardiovascular Risk Factor Reduction in Adults. A Scientific Statement From the American Heart Association. Circulation. 2010;122:406-441. Available at: http://circ.ahajournals.org/cgi/reprint/CIR.0b013e3181e8edf1.

Lichtenstein AH, Appel LJ, Brands M, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation. 2006;114:82-96.

Haskell WL, Lee IM, Pate RR, et al. Physical activity and public health: updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116:1081-1093.

Carels RA, Darby L, Cacciapaglia HM, et al. Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach.

Health Psychol. 2007;26:369-374.

Napolitano MA, Fotheringham M, Tate D, et al. Evaluation of an Internet-based physical activity intervention: a preliminary investigation.

Ann Behav Med. 2003;25:92-99.

visit www.physiciansweekly.com

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January 10, 2011 Click here to view this article online.

Making the Case for Statins

Only about 20% of stroke patients are discharged from the hospital with statin therapy, but adhering to guidelines and partaking in quality improvement efforts may enhance the provision of this important evidence-based therapy.

Lee H. Schwamm, MD Professor of Neurology Harvard Medical School Vice-Chairman of Neurology Director of TeleStroke & Acute Stroke Services Massachusetts General Hospital

A

ccording to national guidelines, patients with ischemic stroke or transient ischemic attack (TIA) should be put on lipid-lowering therapies such as statins during hospitalization. They should continue

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this treatment even after they are discharged, along with plans for proper diet and exercise. This is a top tier recommendation because studies have shown that lipid-lowering medications and statins, in particular, can dramatically lower the rates of subsequent heart attacks, strokes, and the need for procedures to reopen clogged arteries.

Statin Usage Following Acute Stroke Cholesterol-lowering targets have been established by recommendations from the National Cholesterol Education Project Adult Treatment Panel III for

patients with documented coronary heart disease and those that have had an ischemic stroke or TIA. For patients who have no other manifestations of atherosclerosis (other than cerebrovascular disease), the latest American Heart Association (AHA)/American Stroke Association (ASA) guidelines recommend intensive lipid-lowering therapy. “We know from prior experience that medications started at the time of discharge are much more likely to be continued by patients in the year after the event,” explains Lee H. Schwamm, MD. “Starting lipid-lowering medications, especially statins, at discharge in appropriately selected patients

hospitalized for ischemic stroke or TIA makes good sense and should be considered good clinical practice.”

Important New Data & Findings To determine if the national trends in statin use at discharge following an acute stroke were increasing over the last few years, Dr. Schwamm and colleagues reviewed and evaluated patient data from 2005 through 2007 in institutions that were part of the AHA/ASA’s Get With The Guidelines–Stroke (GWTG–Stroke) initiative, a nationwide quality improvement registry.

The study, published in the July 2010 issue of Stroke, visit www.physiciansweekly.com

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Hospital Discharge Use of Lipid-Lowering Medications Figure

The figure below depicts the frequency of hospital discharge use of lipid-lowering medications, including statins, among Get With The Guidelines-Stroke patients hospitalized with ischemic stroke or transient ischemic attack between January 2005 to December 2007. The arrow indicates the period during which Stroke Prevention by Aggressive Reduction in Cholesterol Levels trial results were reported.

Rate of Lipid-Lowering Medication Use

100% 90% 80% 70% 60%

SPARCL

50% 40% 30%

Lipid Medication

20%

Statin

10% 0% 2

20 20 20 20 20 20 20 20 20 20 20 5m 05m 05m 05m 06m 06m 06m 06m 07m 07m 07m 07m 10 7 1 4 7 4 7 1 1 4 10 10

00

Date Source: Adapted from: Ovbiagele, et al. Stroke. 2010;41:1508-1513.

used data from eligible stroke and TIA patients and assessed discharge statin use over time and in relation to dissemination of results from the Stroke Prevention

by Aggressive Reduction in Cholesterol Levels (SPARCL) trial. SPARCL demonstrated that statins appear to reduce vascular risk among patients with atherosclerotic stroke or TIA. Researchers analyzed data on 173,284 hospitalized stroke patients that were involved in GWTG–Stroke throughout the United States. The overall discharge rate of statin treatment was 83.5% in the investigation.

The frequency of discharge statin prescription climbed steadily but modestly over the 2-year study period, increasing from 75.7% to 84.8%. There was a nonsignificant increase during reporting of the SPARCL trial, but a return to prior levels thereafter (Figure).

Risk Factors for Poor Statin Prescription at Discharge In the study published in Stroke, Dr. Schwamm and colleagues identified multiple patient and hospital level factors that were associated with lower rates of statin prescription at discharge (Table). Being female or a non-Caucasian patient reduced the likelihood of 20

receiving treatment. Other factors identified as lowering the likelihood of receiving statins included: • Suffering a TIA instead of a stroke.

• Atrial fibrillation.

• Ownership of a prosthetic heart valve.

Patients taking a cholesterol medication prior to admission were eight times more likely to leave the hospital with a prescription for the therapy when compared with patients who were not on cholesterol medication before admission. Smaller hospitals and those located in the southern region of the United States were less likely to issue statin prescriptions than larger hospitals and those in other areas of the country. A surprising finding was that academic hospitals were also less likely to comply with providing stroke patients with a statin at discharge. Dr. Schwamm notes that this may be due to high rates of trainees and staff turnover at these institutions.

It should be noted that GWTG–Stroke is a voluntary program. “Because hospital partici­pation is voluntary, hospitals in GWTG-Stroke may have higher compliance with preventive recommendations than those that don’t participate in the program,” Dr. Schwamm explains. “We have limited information on the performance of hospitals not participating. Therefore, efforts should be made to get as many hospitals as possible to participate in national stroke quality improvement programs such as GWTG-Stroke. It is becoming quite clear that these programs can improve the delivery of care over time.”

The Time is Now According to Dr. Schwamm, physicians and nurses who care for stroke or TIA patients should familiarize themselves with the latest stroke prevention and treatment guidelines, which are available at www.heart.org.

“It’s important that the entire stroke care management team be up to date so that all stroke symptoms can be recognized. A keen awareness of the appropriate steps in hospital-based secondary prevention efforts for stroke is also paramount. Statin therapy or secondary stroke prevention is an important element in the stroke treatment tool kit, equally as important as the use of aspirin or cessation of smoking.”

In hospitals already partaking in quality improvement efforts like GWTG–Stroke, Dr. Schwamm says

physicians providing care in these facilities should understand the key achievement and quality measures. “These programs enable hospitals to measure

Table

compliance with evidence-based care so that better outcomes can be achieved. Even high-performing hospitals can benefit from such programs.”

Factors Affecting Discharge Statin Use

Covariates

Description

OR

Age

Per 10 years

0.929

Sex

Female vs male

0.869

Race

White vs other

0.870

Index hospitalization

TIA vs ischemic stroke

0.640

History of stroke or TIA

Yes vs no

0.857

History of CAD/prior myocardial infarction

Yes vs no

0.953

History of carotid stenosis

Yes vs no

1.100

History of diabetes

Yes vs no

0.992

History of hypertension

Yes vs no

1.048

History of peripheral vascular disease

Yes vs no

0.903

History of smoking

Yes vs no

1.234

History of dyslipidemia

Yes vs no

1.988

Taking cholesterol reducer at admission

Yes vs no

8.467

History of or current atrial fibrillation

Yes vs no

0.704

Prosthetic heart valve

Yes vs no

0.787

Per 100-unit change

1.033

Academic vs non-academic

0.746

Midwest vs West

0.717

Northeast vs West

0.907

South vs West

0.656

0–100 vs 301+

0.669

101–300 vs 301+

0.882

No. of hospital beds Hospital type Region

No. of stroke discharges Abbreviations: OR, odds ratio; TIA, transient ischemic attack; CAD, coronary artery disease.

Source: Adapted from: Ovbiagele, et al. Stroke. 2010;41:1508-13.

Lee H. Schwamm, MD has indicated to Physician’s Weekly that he serves as chair of the AHA GWTG steering committee, has received research support from the NIH/NINDS, HRSA, and CDC, and is a consultant for the Massachusetts Department of Public Health, RTI Health, Phreesia, and Cryocath/Medtronic. For more information on this article, including references, please visit: www.physiciansweekly.com.

References Ovbiagele B, Schwamm LH, Smith EE, et al. Recent nationwide trends in discharge statin treatment of hospitalized patients with stroke.

Stroke. 2010;41:1508-1513.

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report. Circulation. 2002;106:3143-3421.

Amarenco P, Bogousslavsky J, Callahan A III, et al. High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med. 2006;355:549-559.

Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke. 2008;39:1647-1652.

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