Many post-MI patients are not receiving optimal therapy Content Points: Data from the National Registry of Myocardial Infarction-3 suggest that current strategies for cardiovascular risk reduction are not being applied in an optimal manner.47 A series of landmark clinical studies conducted in the last two decades with angiotensin-converting enzyme (ACE) inhibitors, b-blockers, and statins show that these drugs can markedly reduce the risk of cardiovascular mortality and morbidity. However, as shown on the slide, many patients who could benefit from these drugs are not receiving them.

CHAMP: Hospital-initiated program for post-AMI management Content Points: The Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) focused on initiation of aspirin, cholesterol-lowering medication (statins) to reduce LDL-C to <100 mg/dL, β-blockers, and ACE inhibitors in hospital for post-MI patients.48 Initiation of therapy in post-AMI patients was as follows (unless there were contraindications): – Aspirin was recommended on initial presentation with a maintenance dose or 81 mg or 325 mg. – Statins were initiated in all patients with an LDL-C ≥100 mg/dL during hospitalization. If baseline lipids were not measured within 12 hours post-AMI, a statin was initiated empirically. – ACE inhibition was initiated 12 to 24 hours after admission. – β-blockers were initiated or continued on initial presentation. Medications were initiated in conjunction with counseling on diet, exercise, and smoking cessation before hospital discharge. The objectives were to assess the impact of this program on secondary prevention, to demonstrate the feasibility and safety of initiating cholesterol-lowering medications before hospital discharge, and to determine the impact on clinical outcomes. In this report, treatment rates and clinical outcomes were compared in patients discharged after acute MI in the two-year period before the study (1992 to 1993, n = 256) and the two-year period after CHAMP was implemented (1994 to 1995, n = 302).

CHAMP: Medication utilization rates at discharge in post-AMI patients Content Points: Medical therapy utilization rates at the time post AMI patients were discharged from the hospital changed substantially after CHAMP was implemented.48 As compared with pre-CHAMP patients, use of aspirin increased from 78% to 92%, use of ACE inhibition increased from 4% to 56%, use of statins increased from 6% to 86%, and use of β-blockers increased from 12% to 61% (all P < 0.01). Follow-up data show that there was good compliance with treatment at 1 year. Compliance with statin therapy was 91%. The effect of CHAMP on clinical outcomes is summarized in the next slide.

CHAMP: Reduction in clinical events at 1 year Content Points: Implementation of the CHAMP program was associated with an improvement in clinical outcomes at 1 year in post-AMI patients compared with pre-CHAMP outcomes.48 There were significant reductions in recurrent MI, hospitalizations, cardiac mortality, and total mortality (P < 0.05).

CHAMP: LDL-C levels during follow-up Content Points: During the 6- to 18-month period after hospital discharge, only 6% of the pre-CHAMP patients had an LDL-C of ≥100 mg/dL compared with 58% of the post-CHAMP patients.48 Another sharp contrast was that no post-CHAMP patient had an LDL-C of >160 mg/dL, as contrasted with 14% of the pre-CHAMP patients.

     Statin treatment in acute coronary syndromes: Ensuring a continuum of care Content Points: The results of recent statin trials provide impetus for the implementation of aggressive risk reduction strategies in patients with coronary atherosclerosis, including those with recent acute coronary syndromes. Prevention is now a viable therapeutic goal.49 All patients admitted to a health-care facility with a presumed coronary syndrome should have their lipids measured and adequately treated before discharge. Early initiation of lipid management improves compliance and increases the likelihood of reaching and maintaining an LDL-C of <100 mg/dL. Postponing lipid management until weeks or months after a coronary event may lower compliance and lead to under-treatment of lipid disorders. Continued monitoring of lipid levels is equally important to ensure that patients reach their target and maintain it.