- Email: [email protected]
Statins in the Medical Management of Postoperative Coronary Artery Bypass
12 Reeder GS, Khandheria BK, Seward JB, et al. Transesophageal echocardiography and cardiac masses. Mayo Clin Proc 1991; 66:1101–1109 13 Pop G, Sutherland GR, Koudstaal PJ, et al. Transesophageal echocardiography in the detection of intracardiac embolic sources in patients with transient ischemic attacks. Stroke 1990; 21:560 –565 14 Obeid AI, Carlson RJ. Evaluation of pulmonary vein stenosis by transesophageal echocardiography. J Am Soc Echocardiogr 1995; 8:888 – 896 15 Mohr-Kahaly S, Erbel R, Kearney P, et al. Aortic intramural hemorrhage visualized by transesophageal echocardiography. J Am Coll Cardiol 1994; 23:658 – 664 16 Smith MD, Cassidy JM, Souther S, et al. Transesophageal echocardiography in the diagnosis of traumatic rapture of the aorta. N Engl J Med 1995; 332:356 –362 17 Goldstein SA, Mintz G, Lindsay J. Aorta: comprehensive evaluation by echocardiography and transesophageal echocardiography. J Am Soc Echocardiogr 1993; 6:634 – 659 18 Dressler FA, Craig WR, Castello R, et al. Mobile aortic atheroma and systemic emboli: efficacy of anticoagulation and influence of plaque morphology on recurrent stroke. J Am Coll Cardiol 1998; 31:134 –138
Statins in the Medical Management of Postoperative Coronary Artery Bypass CHEST (see page 455) contains an T hisarticleissuebyofKhanderia et al that describes an
experience at the University of Michigan concerning the incorporation of statins in the medical management of postoperative coronary artery bypass patients. The authors do an excellent job of describing the basic science that supports the incorporation of statins into the postoperative medical regimen of patients who have undergone coronary bypass grafting. There appears to be little doubt that statins are associated with improved outcomes in these patients. The evidence appears to be undeniable that statins should be a part of every postoperative coronary bypass patient’s regimen unless there is some genuine reason for exclusion such as hepatic toxicity. The authors describe an effort that they made to integrate this paradigm shift into their hospital. They undertook an educational program that was targeted at the surgeons who were the final decision makers. Their educational efforts are commendable; however, they fell short of the optimal target in terms of the percentage of patients receiving statins either in the short or long term. The authors did point out that protocol patients were more likely to receive statins than the retrospective controls subjects. Statins were initiated in only 75% of those patients believed by the authors to be eligible. The authors monitored liver function study results and cholesterol target levels in approximately half of their patients. There
www.chestjournal.org
were no cases of rhabdomyolysis or significant elevation of liver functions studies in the authors’ study group. The statin treatment rates dropped to 67% of eligible patients still receiving statins at 6 months following discharge. The authors quite rightly point out that their protocol was “passive.” The incorporation of statins into the postoperative management of patients depended upon an educational effort to be followed by a change in practice patterns, which in retrospect did not achieve compliance at the level the authors had hoped. The surgeons involved in this group of patients had concerns about statin therapy, in that they believed that hepatic dysfunction following surgery was relatively common, and they did not want to compound that with the addition of statins. The authors’ study documented that liver function study results did not significantly deteriorate in patients placed on statins, which is likely reasonable evidence that the concerns about initiating statin therapy are probably overly cautious. The net benefit accrued to patients by putting them on statins probably outweighs to a significant degree the potential for complications associated with statins. The authors mention in their article that they are making efforts to overcome the resistance to the incorporation of statins into their postoperative management. It will be interesting to follow their efforts. We have taken another approach to this problem. We have made initiations of statins “semiautomatic” following coronary artery bypass surgery. This approach has necessitated that the caregivers do something “active” in order to discontinue statins. This approach has resulted in ⬎90% compliance with the recommendations that patients be receiving a statin drug at the time of discharge. We do not have data to document what percentage of our patients are receiving statins at 6 months. It may be improper to conclude that our approach to the management of these patients while in the hospital results in better long-term compliance. It does suggest, however, that a more active approach to the initiation of statins is more productive in getting patients discharged receiving this important medicine. This article points out a very interesting problem in the delivery of medical care in general. Guidelines have been put together for almost every illness and medical condition imaginable, and they contain the very best evidence available about the management of patients with the various problems that they target. Achieving compliance with guidelines has presented an extremely challenging problem in a genCHEST / 127 / 2 / FEBRUARY, 2005
423
eral sense. The authors’ article demonstrates the difficulty of using the “education” approach to achieving compliance with consensus guidelines. As we all struggle with this particular issue, I am convinced that a more active approach to the incorporation of consensus guidelines is the best way to achieve greater levels of compliance. Information technology can be used as a prompting mechanism so that once a diagnosis is established it would require an active intervention on the part of the caregiver in order to prevent “the right thing” from being done. This approach to medicine raises the specter of “cookbook” approaches, “Big Brother,” and the loss of doctor/patient interaction. All of these issues are legitimate and of concern; however, it will become progressively more important for us as a profession to face and solve this issue. In an age of consumerism, our customers deserve our very best. It’s clear that at times we miss that mark. This article is documentation of that fact. A conscientious group of physicians in an excellent institution did this work and wrote the article. The health-care providers involved in the care of these patients clearly have the very best interests of their patients in mind; however, when we look at the results of their attempt to include statins in the postoperative management of cardiac surgery patients, a fairly straightforward clinical recommendation, we and they are disappointed at the level of compliance. Another approach is needed. John C. Alexander, Jr, MD Hackensack, NJ Dr. Alexander is Professor of Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ) at Newark and Chief of Cardiac Surgery at Hackensack University Medical Center. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: John C. Alexander, Jr, MD, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601; e-mail: [email protected]
The Pathology of Lone Atrial Fibrillation atrial fibrillation (AF) is AF in the absence of L one structural heart disease. Persistent lone AF is a
paroxysm that does not spontaneously resolve. The article by Paraskevaidis et al in this issue of CHEST (see page 488) concerns the use of echocardiography to predict the successful cardioversion of persistent lone AF and, perhaps more importantly, the maintenance of sinus rhythm. To accomplish this, the authors used a relatively new echocardiographic
424
measurement, the absence of a “notch” in the early systolic mitral annulus motion (if you will, the absence of NESMAM). Keep in mind that left atrial enlargement and other previously described echocardiographic predictors of the maintenance of sinus rhythm measure cardiac structure, and that structural disease is absent by definition in patients with lone AF. Left atrial appendage flow velocity1 has been used but is based on data from a population that has or is at risk for structural disease. Is the use of cardioversion in patients with persistent lone AF warranted in the first place? There is a risk using antiarrhythmic drugs. Cardioversion to sinus rhythm has not reduced the incidence of subsequent thromboembolism compared to anticoagulation therapy.2–5 Even palpitations are generally not worrisome (except perhaps to the physician), and quality of life is not improved by treatment to maintain sinus rhythm.6 Presumably, the inauspicious results of treatment are because the treatment is not a “permanent fix,” and paroxysms of AF are not 100% eliminated. However, treatment would make more sense if one could predict which individuals would receive a permanent fix with cardioversion for the treatment of AF. The idea that we can identify patients who better respond to treatment would seem to make the diagnosis of lone AF an oxymoron, because the term lone implies no distinguishing features: the AF stands alone. The duration of AF is generally not useful to consider in this regard (it was not in this study) because patients with persistent lone AF usually present for treatment rather soon after onset of the condition. Otherwise, the classic indications that AF will recur subsequent to cardioversion, such as left atrial size, depend on a structural change. Yet, Paraskevaidis et al have suggested that we can predict who will benefit in the long term from cardioversion of lone AF by Doppler interrogation of the left atrial appendage and analysis of mitral annulus motion on M-mode echocardiography. A flow velocity of ⬎ 20 cm/s was useful. More importantly, often in AF (in two thirds of their lone AF patients) there is NESMAM. The notch was seen in 88% of patients who went on to revert to AF after undergoing cardioversion but was absent in 90% of those who remained in sinus rhythm at the 1-year follow-up. The data of Paraskevaidis et al require confirmation but would clarify an otherwise confusing and controversial issue regarding the selection of patients with lone AF for cardioversion. It would be even more exciting to learn whether the absence of NESMAM predicts the maintenance of sinus rhythm in a population of patients who have undergone cardioversion but were then not treated with antiarEditorials
Statins in the Medical Management of Postoperative Coronary Artery Bypass CHEST (see page 455) contains an T hisarticleissuebyofKhanderia et al that describes an
experience at the University of Michigan concerning the incorporation of statins in the medical management of postoperative coronary artery bypass patients. The authors do an excellent job of describing the basic science that supports the incorporation of statins into the postoperative medical regimen of patients who have undergone coronary bypass grafting. There appears to be little doubt that statins are associated with improved outcomes in these patients. The evidence appears to be undeniable that statins should be a part of every postoperative coronary bypass patient’s regimen unless there is some genuine reason for exclusion such as hepatic toxicity. The authors describe an effort that they made to integrate this paradigm shift into their hospital. They undertook an educational program that was targeted at the surgeons who were the final decision makers. Their educational efforts are commendable; however, they fell short of the optimal target in terms of the percentage of patients receiving statins either in the short or long term. The authors did point out that protocol patients were more likely to receive statins than the retrospective controls subjects. Statins were initiated in only 75% of those patients believed by the authors to be eligible. The authors monitored liver function study results and cholesterol target levels in approximately half of their patients. There
www.chestjournal.org
were no cases of rhabdomyolysis or significant elevation of liver functions studies in the authors’ study group. The statin treatment rates dropped to 67% of eligible patients still receiving statins at 6 months following discharge. The authors quite rightly point out that their protocol was “passive.” The incorporation of statins into the postoperative management of patients depended upon an educational effort to be followed by a change in practice patterns, which in retrospect did not achieve compliance at the level the authors had hoped. The surgeons involved in this group of patients had concerns about statin therapy, in that they believed that hepatic dysfunction following surgery was relatively common, and they did not want to compound that with the addition of statins. The authors’ study documented that liver function study results did not significantly deteriorate in patients placed on statins, which is likely reasonable evidence that the concerns about initiating statin therapy are probably overly cautious. The net benefit accrued to patients by putting them on statins probably outweighs to a significant degree the potential for complications associated with statins. The authors mention in their article that they are making efforts to overcome the resistance to the incorporation of statins into their postoperative management. It will be interesting to follow their efforts. We have taken another approach to this problem. We have made initiations of statins “semiautomatic” following coronary artery bypass surgery. This approach has necessitated that the caregivers do something “active” in order to discontinue statins. This approach has resulted in ⬎90% compliance with the recommendations that patients be receiving a statin drug at the time of discharge. We do not have data to document what percentage of our patients are receiving statins at 6 months. It may be improper to conclude that our approach to the management of these patients while in the hospital results in better long-term compliance. It does suggest, however, that a more active approach to the initiation of statins is more productive in getting patients discharged receiving this important medicine. This article points out a very interesting problem in the delivery of medical care in general. Guidelines have been put together for almost every illness and medical condition imaginable, and they contain the very best evidence available about the management of patients with the various problems that they target. Achieving compliance with guidelines has presented an extremely challenging problem in a genCHEST / 127 / 2 / FEBRUARY, 2005
423
eral sense. The authors’ article demonstrates the difficulty of using the “education” approach to achieving compliance with consensus guidelines. As we all struggle with this particular issue, I am convinced that a more active approach to the incorporation of consensus guidelines is the best way to achieve greater levels of compliance. Information technology can be used as a prompting mechanism so that once a diagnosis is established it would require an active intervention on the part of the caregiver in order to prevent “the right thing” from being done. This approach to medicine raises the specter of “cookbook” approaches, “Big Brother,” and the loss of doctor/patient interaction. All of these issues are legitimate and of concern; however, it will become progressively more important for us as a profession to face and solve this issue. In an age of consumerism, our customers deserve our very best. It’s clear that at times we miss that mark. This article is documentation of that fact. A conscientious group of physicians in an excellent institution did this work and wrote the article. The health-care providers involved in the care of these patients clearly have the very best interests of their patients in mind; however, when we look at the results of their attempt to include statins in the postoperative management of cardiac surgery patients, a fairly straightforward clinical recommendation, we and they are disappointed at the level of compliance. Another approach is needed. John C. Alexander, Jr, MD Hackensack, NJ Dr. Alexander is Professor of Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ) at Newark and Chief of Cardiac Surgery at Hackensack University Medical Center. Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail: [email protected]). Correspondence to: John C. Alexander, Jr, MD, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601; e-mail: [email protected]
The Pathology of Lone Atrial Fibrillation atrial fibrillation (AF) is AF in the absence of L one structural heart disease. Persistent lone AF is a
paroxysm that does not spontaneously resolve. The article by Paraskevaidis et al in this issue of CHEST (see page 488) concerns the use of echocardiography to predict the successful cardioversion of persistent lone AF and, perhaps more importantly, the maintenance of sinus rhythm. To accomplish this, the authors used a relatively new echocardiographic
424
measurement, the absence of a “notch” in the early systolic mitral annulus motion (if you will, the absence of NESMAM). Keep in mind that left atrial enlargement and other previously described echocardiographic predictors of the maintenance of sinus rhythm measure cardiac structure, and that structural disease is absent by definition in patients with lone AF. Left atrial appendage flow velocity1 has been used but is based on data from a population that has or is at risk for structural disease. Is the use of cardioversion in patients with persistent lone AF warranted in the first place? There is a risk using antiarrhythmic drugs. Cardioversion to sinus rhythm has not reduced the incidence of subsequent thromboembolism compared to anticoagulation therapy.2–5 Even palpitations are generally not worrisome (except perhaps to the physician), and quality of life is not improved by treatment to maintain sinus rhythm.6 Presumably, the inauspicious results of treatment are because the treatment is not a “permanent fix,” and paroxysms of AF are not 100% eliminated. However, treatment would make more sense if one could predict which individuals would receive a permanent fix with cardioversion for the treatment of AF. The idea that we can identify patients who better respond to treatment would seem to make the diagnosis of lone AF an oxymoron, because the term lone implies no distinguishing features: the AF stands alone. The duration of AF is generally not useful to consider in this regard (it was not in this study) because patients with persistent lone AF usually present for treatment rather soon after onset of the condition. Otherwise, the classic indications that AF will recur subsequent to cardioversion, such as left atrial size, depend on a structural change. Yet, Paraskevaidis et al have suggested that we can predict who will benefit in the long term from cardioversion of lone AF by Doppler interrogation of the left atrial appendage and analysis of mitral annulus motion on M-mode echocardiography. A flow velocity of ⬎ 20 cm/s was useful. More importantly, often in AF (in two thirds of their lone AF patients) there is NESMAM. The notch was seen in 88% of patients who went on to revert to AF after undergoing cardioversion but was absent in 90% of those who remained in sinus rhythm at the 1-year follow-up. The data of Paraskevaidis et al require confirmation but would clarify an otherwise confusing and controversial issue regarding the selection of patients with lone AF for cardioversion. It would be even more exciting to learn whether the absence of NESMAM predicts the maintenance of sinus rhythm in a population of patients who have undergone cardioversion but were then not treated with antiarEditorials