Download GUIDELINES IMPLEMENTATION Practical Application of the

GUIDELINES IMPLEMENTATION
Practical Application of the New Canadian Guidelines for Cardiac
Rehabilitation and Secondary Prevention: A Case Study - Part 3
James A. Stone, MD, PhD, FRCPC, Chair and Editor-in-Chief, CACR Guidelines Committee and
Guidelines; President CACR
In Part I of the present Case Study, a 47 y.o. farm worker with multiple heart hazards and a six-month
history of exertional heartburn was presented. By utilizing the risk stratification strategies detailed
within the CACR Guidelines, we established that this man had a very high absolute risk of developing
overt symptoms of atherosclerotic heart disease and was falsely reassured about his future risk of
disease expression. In Part 2, our high-risk patient went on to suffer a heart attack and subsequently
underwent coronary artery bypass surgery for severe multivessel disease. He was referred for
cardiac rehabilitation and, again using the CACR Guidelines, we were able to risk stratify this man
with respect to disease prognosis (his risk of exercise-related or short-term risk of cardiac events)
and his disease progression or long-term disease risk. In this third and final article, we will finish by
examining his specific treatment targets and the CACR recommendations regarding his heart
hazards.
Home, home on the (heart hazard) range.
When we left our 47 y.o. farmhand, he had just entered a program of cardiac rehabilitation. On
admission to the program, it was established that his disease prognosis was excellent but his risk of
disease progression was high. Thus, for this patient, the need for long-term strategies and goals,
emphasizing the need to treat to target, is particularly important in maximizing his longevity and
productivity.
Heart Hazard Treatment Targets
At the end of Part 1 of this case presentation, the CACR recommended heart hazard treatment
targets, relevant to this gentleman, were presented.
Lipid Treatment Targets
TC/HDL < 4.0
TG < 1.8 mmol/L
HDL > 1.0 mmol/L
LDL < 2.5 mmol/L
Case Specific CACR Dyslipidemia Recommendations (Page 88-89)
5.10 Patients with acute myocardial infarction should have a fasting lipid profile measured on
admission or within the first 24 hours. Post-myocardial infarction patients, in whom a fasting lipid
profile was not obtained within the first 24 hours, should delay assessment of their fasting lipid
profile for approximately two months. Grade B, Level II
5.11 All patients hospitalized with ischemic/coronary heart disease - post-myocardial infarction,
unstable angina, post-PTCA, post-CABG, ischemic congestive heart failure - should have a
fasting lipid profile performed prior to hospital discharge and immediate pharmacological therapy
is recommended for patients with LDL ³ 3.2 mmol/L or a TC/HDL ratio ³ 4.0.. Grade B, Level I.
5.12 Target levels. All adults with documented cardiovascular disease should adopt appropriate
dietary lifestyle modifications to achieve lipid level targets. Grade A, Level II
5.13 Target ratios. All adults with documented cardiovascular disease should adopt appropriate
dietary and lifestyle modifications to achieve a target TC/HDL ratio of less than 4.0. Grade A,
Level II
These goals are based on information derived from large, randomized clinical trials. The information
supporting the use of TC/HDL ratio as a treatment target is mostly derived from retrospective patient
population studies. Secondary prevention studies have mainly targeted LDL as their primary
treatment target. If your patients are to derive at least similar improvements in cardiovascular
morbidity and mortality, then they must be treated to the same targets used in the clinical trials that
proved the therapeutic benefits. As always it is important to remember that these treatment targets
are only guidelines. Patients may be treated more aggressively or less aggressively depending on
individual circumstances. Indeed, many cardiologists now advocate treating patients with CAD to an
LDL target of less than 2.2 mmol/L. However, if the majority of patients within your program are not
treated to target, then you should question whether all of your patients are exceptions in whom the
treatment targets do not apply. And, if you do not prospectively collect and analyze heart hazard
information within your program, then you have no hope of determining how you are doing regarding
treating to target. This lack of documentation and information analysis is no longer congruent with
good clinical practice.
In our patient, all his lipid values are not at target. Furthermore, his TC/HDL of 7.0 and his LDL of 4.1
mmol/L are sufficiently high to warrant immediate pharmacological intervention. This must be initiated
with the required dietary modifications congruent with achieving his lipid targets. If he obtains and
sustains the needed dietary and lifestyle modifications, he may be able to reduce or even discontinue
his lipid modifying therapy in the years to come. For his particular lipid profile, the usual initial
medication would be a statin and possibly a fibric acid derivative (to increase HDL and lower TG) and
niacin.1 It is important to note that his LDL is more than 40% above target. In these circumstances,
higher doses of medication will be required to achieve target and may be initiated as initial therapy.
As always, a careful check should be made of liver enzymes and CK every 3-6 months for all patients
on these medications. This surveillance is critical for patients on combination therapy.
Hypertension Treatment Targets
Non-diabetic < 140/90 mmHg
Diabetic or renal dysfunction < 130/80 mmHg
Proteinuria (> 1 g/day) < 125/75 mmHg
Case Specific CACR Hypertension Recommendations (Page 102)
5.23 All patients with documented cardiovascular disease should have the blood pressure controlled
to less than 140/90 mmHg. Grade B, Level I
5.24 Aggressive and purposeful lifestyle modification should be used in all patients with documented
hypertension in an effort to reduce and/or control blood pressure. Grade A, Level II
These hypertension treatment targets are consistent with the 2001 Canadian Hypertension
Recommendations.2 In lowering blood pressure, the average expected decrease with any medication
is approximately 10/5 mmHg. Initial, first-line choices for anti-hypertensive agents (assuming no
specific contraindications) include diuretics, beta-blockers (BB), long-acting dihydropyridine calcium
channel blockers (DCCB), or ACE inhibitors (ACEI). If the initial medication choice is not successful in
reaching target, then a combination of medications is recommended. Anti-hypertensive combinations
that have an additive hypotensive effect are BB's or ACEI's in combination with a diuretic, a DCCB, or
a non-DCCB. When aggressive combinations of medications fail to get patients to their pre-specific
treatment target, consideration should be given to the importance of non-compliance, white coat
hypertension, drug interactions, adverse lifestyles (sedentary, on-going tobacco abuse), and causes
of secondary hypertension.1
It cannot be emphasized enough that proper measurement of blood pressure is essential to
diagnosing and treating hypertension. Most health care professionals do not follow proper procedures
in measuring blood pressure and would do well to review the techniques previously described.3
Our patient was discharged home on a BB and an ACEI. This combination was chosen, not based on
his hypertension, but based on current post-MI recommended medications. During his follow-ups in
cardiac rehabilitation, multiple resting measurements established that he had persistent hypertension.
Up titration of his BB to achieve a resting HR of 50-60 bpm and addition of a diuretic normalized his
resting BP to 134/78 mmHg. Most patients will require at least two medications to achieve their BP
target level with a significant minority (as many as 40%) needing three or four medications. Diabetics,
in particular, often require four medications to get to their treatment target of < 130/80 mmHg.
Smoking Cessation Treatment Targets
Total abstinence.
Case Specific CACR Smoking Cessation Recommendations (Page 116)
5.34 The smoking status (smoker, former smoker, never smoked, passive smoker) should be
established and documented for all persons interacting with health-care professionals. Grade A,
Class III
5.35 All smokers should receive nonjudgmental, clear, and unambiguous advice to stop all forms of
smoking and to avoid exposure to second hand smoke. Grade A, Class III
5.36 Smoking cessation programs must be considered requisite elements for all health-care
programs, particularly those dealing directly with cardiovascular disease. Access to smoking
cessation programs and encouragement to attend these programs should be provided to all
smokers and their families. Grade A, Class III
5.37 All smokers should have documented evidence from their physicians and/or other health-care
professionals regarding the absolute need to stop smoking. Grade A, Class III
5.38 In addition to cigarette smoking, all other forms of tobacco consumption, including cigar
smoking, should be discouraged. Grade A, Class III
5.39 All physicians, including both primary care physicians and cardiovascular specialists alike,
should be familiar with the appropriate use of nicotine replacement therapy and other
therapeutic initiatives demonstrated to be helpful in smoking cessation. Grade A, Class III
Total abstinence is the only acceptable treatment target. Patients with CVD and CAD, who continue
to smoke, have very shortened event free intervals and lives. In any co-habitation arrangement, both
partners must agree to a non-smoking policy if the affected partner is to have any chance at all of
achieving complete smoking cessation. Furthermore, the severe adverse effects of passive smoking
are now well documented.4
In our patient, the "cold turkey" approach worked. His spouse did not smoke. The majority of patients
will require multiple attempts to quit smoking and both non-pharmacological and pharmacological
strategies, as documented in the CACR guidelines (pages 115-116), will be beneficial.
Exercise/Physical Activity Treatment Targets
Thirty minutes or more of moderate intensity physical activity on most, preferably, all days of the
week.
Case Specific CACR Physical Activity Recommendations (Page 121-122)
5.43 Most persons with documented cardiovascular disease would benefit from a regular physical
activity program, with improvements in cardiovascular morbidity and mortality, after appropriate
medical assessment and prescriptive exercise counseling. Grade B, Level I
5.44 Low risk persons with documented cardiovascular disease may be appropriate for home
exercise programs or self supervised physical activity programs following a period of instruction
and exercise acclimatization. Grade C, Level III
5.45 Persons at intermediate or high-risk for cardiovascular disease progression or recurrent events
should participate in exercise programs supervised and monitored by appropriately trained
health-care professionals with substantial experience in these patient services. Grade B, Level
III
5.46 Participation in exercise and physical activity programs should be incorporated into a lifelong
program of heart healthy living. Patients and their families should be encouraged to participate
in the physical activities they find enjoyable and sustainable. Grade B, Level III.
In our patient, the physical activity goal was designed to return him to an active, physically productive
life as a farm worker. The program chosen for him was one he could pursue at home. His low risk
disease prognosis score made unsupervised, home exercise safe for him. The program stressed
daily activities, consisting mainly of walking sessions, interspersed with his usual physical activities.
The program emphasized the absolute need to avoid prolonged, straining/isometric activities and the
importance of a proper warm up and cool down. The latter aspect was totally foreign to both him and
his employer. However, with the time spent by his exercise specialist to explain these principles, both
he and his employer felt much less fatigued at the end of a busy day. Our patient was told he could
still lift heavy weights. His lifting maximal capacity was determined during a follow-up rehab visit, 5
months post-bypass, and he was told not to exceed this. This is much more effective than clinically
useless statements such as "don't lift more than X pounds" and provides physically active patients
with meaningful, personally relevant lifting parameters.
In closing this case study, we need to touch on the many aspects of comprehensive cardiac
rehabilitation that have not been presented. These include determining and understanding patients'
readiness for change, i.e., stages of change, coaching patients to achieve improved lifestyle and
heart hazard modification adherence and compliance, and the importance of screening for mental
and sexual health as appropriate. However, this case study should give you a feel for how the CACR
Guidelines can help in the proper risk stratification and program planning of patients in cardiac
rehabilitation programs.
References
1. Brown GB, Xue-Qiao Zhao MD, Chait A et al. Simvastatin and Niacin, Antioxidant Vitamins, or the
Combination for the Prevention of Coronary Disease. New Engl J Med; 345:1583-1592
2. Canadian Hypertension Working Group. The 2001 Canadian Hypertension Recommendations.
What's new and what's old but still important. Manuscript in preparation.
3. Canadian Hypertension Working Group. 1999 Canadian Recommendations for the management of
hypertension. CMAJ 1999; Suppl 12
4. Taylor BV, Oudit GY, Kalman PG, Liu P. Clinical and pathophysiological effects of active and
passive smoking on the cardiovascular system. Can J Cardiol 1988: 14: 1129-1139