The Cardiology Evidence Base, whatever its gaps and shortcomings,
is arguably the deepest and highest-quality evidence base available to any
Clinicians can face the challenges of the human burden and
financial cost of heart disease armed with this formidable body of
Translating the available data from words on a journal page into a
concrete plan of action for any single patient under our care is still a
challenge. Guidelines from the American Heart Association and American College
of Cardiology sift, condense and analyze the clinical trial results into
state-of-the-art consensus recommendations for the delivery of the best care
Of course, no guideline statement can replace the role of an
informed and talented clinician in shaping the application of the evidence to
the individual patient seated in the examination room. These consensus
guidelines represent the best available combination of data and expert opinion
in guiding the care of the population as a whole.
Roger S. Blumenthal
The forefront of cardiovascular research and our evidence base are
moving forward at an impressive and satisfying rate. While the leading edge
marches ahead, the tail the large group of Americans with CVD who are
receiving incomplete or inadequate therapy remains woefully mired in
suboptimal care. Our patients stand to gain a great deal by simply focusing on
applying the lessons we have already learned in a more consistent manner.
This gap between guidelines and delivery of care has been
recognized for some years. An analysis of the National Registry of MI database
from 1994 to 2000 found that only 77% of patients hospitalized for MI received
simple aspirin therapy at discharge. Even as recently as 2002, rates of
self-reported aspirin use in patients with CAD hovered at 80%. Disturbingly,
only 60% reported receiving ongoing lipid-modifying therapy.
Much of the effort undertaken to address these short-fallings has
taken the form of top-down, externally-driven initiatives, such as
pay-for-performance incentives and public benchmarking of individual and
institutional adherence to guidelines. Although, undoubtedly, these sorts of
system-wide reforms stand to play a significant role in enhancing our overall
quality of care, there has been relatively little focus on cognitive and
practical interventions at the practitioner level.
We propose a simplified ABCDE guideline structure that
both emphasizes the cornerstone principles of state-of-the-art cardiovascular
prevention and refocuses the understanding of CVD as a continuum of disease
from risk factors to vascular events.
A common pitfall in care, particularly by non-CVD specialists, is
the failure to view atherosclerotic heart disease as a systemic disease carried
forward by multiple common risk factors. Our attention and efforts are largely
driven by the acute events that mark the progression of disease, the infarcts
and strokes, to the point of losing focus on care of the underlying processes
driving the disease. This is precisely the point missed in the widespread
public perception, unfortunately still held by some physicians, that stents and
bypass surgery cure or clean out heart disease. Prompt revascularization is
helpful when an acute coronary syndrome develops, but it is the life-long
attention to that patients hypertension, lipids, weight, dietary habits
and tobacco use that will serve them the best in the long run. The recent
results from COURAGE underscore the fundamental importance of these
disease-modifying therapies in the treatment of atherosclerosis and its
The ABCDE approach simplifies and systematizes lengthy
and complex guidelines into a comprehensive management plan for the primary and
secondary prevention of CVD:
- A: Antiplatelet therapy.
- B: BP control.
- C: Cholesterol-lowering therapy and cigarette cessation.
- D: Diet modification and diabetes prevention of or
management of the condition.
- E: Exercise.
Initially introduced as a summary framework to guide care in the
preventive cardiology center setting, we believe that this algorithm can be an
effective and efficient intervention each time a patient with or at risk for
atherosclerotic heart disease makes contact with the medical system.
Application of this approach by cardiovascular care providers of
all stripes, whether by the nurse in an ICD follow-up visit, the physiologist
in cardiac rehabilitation or a vascular surgeon, would guarantee multiple
layers of redundancy and cross-checking. It also serves the educational purpose
of reinforcing the fundamental importance of aggressive risk factor
modification in every patient undergoing other therapies for consequences of
their heart disease.
The ABCDE framework provides a simplified structure to
enhance adherence to guideline-based therapy and ensure the delivery of the
best available care to our patients. Whether applied as a guide to prescription
of therapy de novo or as a checklist to evaluate ongoing treatment, this is a
systematic and transparent method to broaden the reach of the cornerstone
therapies for CVD and its prevention.
Chris Sibley, MD, is a Fellow at the Johns Hopkins Ciccarone
Center for Prevention of Heart Disease. Juan Rivera, MD, is a Fellow at the
Johns Hopkins Ciccarone Center for Prevention of Heart Disease and a member of
the Today in Cardiology Fellows Advisory Board. Roger S.
Blumenthal, MD, is the Director of the Johns Hopkins Ciccarone Center for the
Prevention of Heart Disease and a Member of the Preventive Cardiology Section
of the Today in Cardiology Editorial Board.
For more information:
- Spencer FA, Meyer TE, Gore JM, Goldberg RJ. Heterogeneity in
the management and outcomes of patients with acute MI complicated by heart
failure: the National Registry of Myocardial Infarction.
- Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to
evidence-based secondary prevention therapies in coronary artery disease.
- Associated Press. Philbin says hell have bypass
surgery. March 12, 2007.