Section 9: Continuum of care: Summary and timeline Revascularization and lipid lowering Content Points: The AVERT study is consistent with other studies that show revascularization alone may not be sufficient to prevent ischemic events.37,53 In contrast, aggressive reduction of LDL-C appears to reduce CHD event rates and should be combined with appropriate revascularization.53

Revascularization and plaque pathology Content Points: As has been discussed, MI frequently evolves from mild-to-moderate obstructive plaques.31 It is not possible for interventionalists to treat all of these risky lesions. Indeed, they are frequently undetectable by angiography.

Continuum of care Content Points: In the context of the previous slide, therefore, a new paradigm of care is proposed that stresses a continuum of care involving both PCI and lipid-lowering therapy working in concert. PCI has a role in treating patients with significant symptoms, to whom it offers immediate benefits, including rapid improvement, improved angina tolerance at rest and during exercise and a reduced need for antianginal drugs. Lipid-lowering therapy is appropriate for all patients with CAD and is of long-term benefit. It treats plaque of all sizes and stages of development, reduces plaque progression and reduces CAD events.

ACT Content Points: This new paradigm can be summarized in the acronym ACT: – Awareness of opportunities to improve outcomes – Create synergies to achieve a continuum of care – Treat LDL-C aggressively

Clinical challenge: Aggressively  LDL-C to  CHD events Content Points: The slide summarizes the relationship between event rate and cholesterol lowering in primary and secondary prevention studies in the context of the NCEP target levels for patients with or without CHD.39 Event rates decreased with successively lower concentrations of LDL-C. The challenge is to help patients achieve their NCEP goal level.

Summary: Postintervention action plan Content Points: Based on current evidence, an appropriate lipid management strategy would include diet and exercise, with pharmacological therapy as indicated by the NCEP guidelines. Importantly, since we are dealing with patients with established atherosclerotic disease, the goal of reducing LDL-C to < 100 mg/dL must be achieved. An important step in reaching that goal will be to involve the patient in the management strategy. Make them aware of their lipid levels and their significance. In one study, 28% of patients with CAD did not know their cholesterol level.54 Patient education materials could also be useful aids to motivating patients and having them play an active role in their treatment.

Postintervention care timeline Content Points: The slide shows a sample critical care pathway that might be followed after PCI. As indicated, there are no currently accepted standards for determining the extent of atherosclerosis and assessing ischemia and a variety of approaches can be envisioned and debated. Prior to disharge, education and planning are essential: First, the patient needs to understand the effect of the PCI on the specific lesion and the future management of that lesion. Second, the patient needs to be aware of the developing atherosclerosis in the rest of the coronary tree and the medications and plans required to address the risk factors of this disease.

Postintervention care timeline Content Points: This slide extends the sample critical care pathway through 3 months following discharge. During this period, the interventional cardiologist can play an important role in establishing the scope of the management plan. There should be regular follow-up with patients, for the purpose of assessing the status of the dilated lesion(s), reinforcing the lipid and other goals, establishing clear expectations and encouraging good compliance. The ideal set of goals should include: – No angina and full activity – No evidence of ischemia on testing – Total cholesterol < 200 LDL < 100 (with LDL being the control parameter) HDL > 40 Triglycerides < 150 – BP < 130/50 –Control of diabetes, smoking cessation, exercise plan, weight reduction

Postintervention care timeline Content Points: The important role of the interventional cardiologist in establishing a continuum of care is highlighted in this final slide, which illustrates the long-term nature of the patient management plan. The specific goals should be personalized for each patient in a clear plan. The interventional cardiologist (and team) are in a key position to initiate, educate and send the appropriate signals to the patient, their family and the community physicians involved.