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Charlene May, Senior Director, Science and Clinical Policy
Tanja Kharlamova, Associate Director, Science and Clinical Policy
Fareen Pourhamidi, MS, MPH, Senior Specialist, Evidence-Based Medicine
María Velásquez, Specialist, Science and Clinical Policy
Erin A. Barrett, Senior Specialist, Science and Clinical Policy
Rose Marie Robertson, MD, FAHA, FACC, FESC, Chief Science Officer
Gayle R. Whitman, PhD, RN, FAHA, FAAN, Senior Vice President, Office of Science Operations
Kathryn A. Taubert, PhD, FAHA, Senior Scientist
The American College of Cardiology Foundation/American Heart Association/American College of Physicians (ACCF/AHA/ACP) Task Force on Clinical Competence was formed in 1998 to develop recommendations for attaining and maintaining the cognitive and technical skills necessary for the competent performance of a specific cardiovascular service, procedure or technology. These documents are evidence-based, and where evidence is not available, expert opinion is utilized to formulate recommendations. Indications and contraindications for specific services or procedures are not included in the scope of these documents. Recommendations are intended to guide curriculum development and assist those who judge the competence of cardiovascular health care providers entering practice for the first time and/or those in practice who undergo periodic review of their expertise or who apply for privileges at a new institution. The assessment of competence is complex and multidimensional, therefore isolated recommendations contained herein may not necessarily be sufficient or appropriate for judging overall competence. The current document addresses a curriculum for developing competence in the prevention of cardiovascular disease (CVD) and is authored by representatives of the ACCF, AHA, ACP, the American Academy of Neurology (AAN), American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR), American College of Preventive Medicine (AAPM), American College of Sports Medicine (ACSM), American Diabetes Association (ADA), American Society of Hypertension (ASH), Association of Black Cardiologists (ABC), Centers for Disease Control and Prevention (CDC), National Heart, Lung, and Blood Institute (NHLBI), National Lipid Association (NLA), Preventive Cardiovascular Nurses Association (PCNA). The recommendations contained herein recognize the broader context of clinical training and the importance of systems of care in improving patient outcomes. Trainees should be aware of and responsive to the larger context of systems-based health care, and utilize all available resources to provide optimum care. Similarly, the development of competence embodies knowledgeable incorporation of technological advances for the evaluation of health and disease based on ongoing familiarity with the emerging scientific and social literature.
The ACCF/AHA/ACP Task Force makes every effort to avoid actual or potential conflicts of interest that might arise as a result of an outside relationship or personal interest of a member of the ACCF/AHA/ACP Writing Committee. Specifically, all members of the Writing Committee are asked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts of interest relevant to the document topic. These statements are reviewed by the Writing Committee and updated as changes occur. The relationships with industry for authors and peer reviewers are published in the appendices of the document. Jonathan L. Halperin, MD, FACC Chair, ACCF/AHA/ACP Task Force on Clinical Competence and Training
Jonathan L. Halperin, MD, FACC
Chair, ACCF/AHA/ACP Task Force on Clinical Competence and Training
The mission of many organizations is the optimal care to those with or at risk for developing CVD (primary and secondary prevention). Over the past two decades, there have been dramatic increases in knowledge concerning specific risk factors in atherosclerosis, hypertension, thrombosis, and other forms of vascular dysfunction. Clinical trials have proven that strategies aimed at the appropriate detection and modification of risk factors can slow progression of atherosclerosis, diabetes mellitus, and hypertension and reduce the occurrence of clinical cardiovascular events in both primary and secondary prevention settings. More recently, it has been shown that atherosclerosis can be stabilized or even modestly reversed. Finally, a new and growing knowledge base of molecular genetics applied to the study of the cardiovascular system has potential relevance to the clinical practice of preventive cardiovascular medicine.
Despite the fact that clinical outcomes can be improved by promotion of favorable life habits and behaviors and by the proper use of drug treatment, the application of primary and secondary preventive interventions in clinical practice is not optimal. Prevention of CVD in both the primary and secondary prevention setting, while dominantly the responsibility of the primary care provider, is increasingly challenged given this ever expanding new knowledge as well as the ongoing problems related to adherence to recommendations. New knowledge in the area of pre-clinical disease detection has presented increasingly challenging scenarios to primary care healthcare providers relative to the decisions regarding the need for further risk stratification and aggressive medical regimens. Furthermore, increasingly complex patients are surviving with CVD, many of whom can benefit from advanced knowledge and expertise with regard to risk factor management and rehabilitation that is beyond traditional general primary and cardiology practitioner's scope of practice.
The prevention of cardiovascular morbidity and mortality is a shared responsibility among all health professionals involved in the care of people at risk of developing cardiovascular disease. This document is directed at those individuals seeking expertise at a leadership level in this field, and includes opportunities for formal training and alternative routes to competence and maintenance of competence in prevention of cardiovascular disease (Table 2), and educational resources for acquisition and maintenance of competence in the prevention of cardiovascular disease (Table 3). To address the expanding fund of knowledge in the area and to ensure that an adequately trained force of preventive cardiovascular leaders will be available to primary care providers, as well as provide a pool of providers with expertise in running rehabilitation and other programs designed to address the ongoing issue of adherence, the formulation of clinical competency criteria for the cardiovascular preventive specialist is needed. These competency criteria are expected to address issues of expert clinical and scientific leadership, specialty patient care and consultation, and directorship of primary and secondary preventive cardiac programs. Of note and similar to other subspecialty areas of medicine, cardiovascular preventive specialists will have varying areas of expertise and will not necessarily achieve all the outlined areas of competencies. These clinical competency criteria in the area of specialty treatment and prevention of CVD are needed given the current setting of a rapidly growing field of knowledge ranging from molecular and cellular mechanisms to clinical outcomes in order to translate into improved patient care.
C. Noel Bairey Merz, MD, FACC, FAHA
Chair, ACCF/AHA/ACP Clinical Competence Statement on Prevention of CVD
Recent advances in cardiac and vascular biology and related molecular and cellular mechanisms provide a sound scientific foundation for the practice of preventive cardiovascular medicine. A basic knowledge of the structure and function of the arterial wall, its interactions with components of the circulating blood, and key pathologic processes such as oxidation, inflammation, thrombosis, and remodeling is important to the application of strategies for the detection, evaluation, and prevention of atherosclerotic CVD (1, 2). Similarly, a basic understanding of myocardial cellular and molecular processes is essential for effective application of therapies that address myocardial salvage, regeneration, and remodeling.
The expert in the prevention of cardiovascular disease should demonstrate knowledge and competence in:
Clinical epidemiology is the study of the magnitude, distribution, and trends in the factors that affect health, disease, and their determinants in populations (7). Within the context of preventive cardiology, clinical epidemiology provides crucial information in the enumeration of CVD events, rates, trends and outcomes in defined populations and their sub-groups. It also permits the identification of populations at different levels of risk for CVD events and the existence of health disparities (8). The surveillance components of clinical epidemiology provide clues to new and emerging CVD threats and permit assessment of the effectiveness of interventions.
Recent emphasis on quality, economic endpoints, and modeling in epidemiologic studies provide an opportunity for epidemiology to inform clinical practice on the cost-effectiveness and health impact of alternative preventive strategies (9–12). In addition, clinical epidemiology serves an important role in informing practitioners about the use of evidence from clinical trials and the strength and generalizability of that evidence. In this endeavor, the related field of biostatistics provides important principles for appropriate design of clinical trials, interpretation of trial results, and the effective use of screening, diagnostic, and prognostic tools in the practice of preventive cardiology (13).
The expert in the prevention of cardiovascular disease should demonstrate knowledge and competence in:
Knowledge of cardiovascular pharmacology, and the basic principles of pharmacokinetics, pharmacodynamics and pharmacogenomics is critical to the targeted application of drug therapy for individual patients. A basic knowledge of drug interactions, anticipated side effects, and dosing regimens in a heterogeneous mix of complex patients is necessary to integrate new research and new approaches for CVD prevention and treatment. The challenges posed by age, gender, reproductive hormones and medical co-morbidities, including the co-existence of disorders known to contribute to cardiac and vascular endothelial dysfunction, must be recognized. Interactions between medication and nutrition (e.g. grapefruit), over the counter supplements (e.g. antioxidant vitamins), nutriceuticals (e.g. stanol/sterol esters), and dietary alcohol intake are increasingly reported and of practical relevance. Knowledge that pharmacologic therapies may have differing impact based on underlying existence of disease and endogenous hormone status, including hormonal therapies, is important. A basic understanding of pharmacology will also be important as new therapies myocardial salvage, regeneration and remodeling become available.
The expert in the prevention of cardiovascular disease should demonstrate knowledge and competence in:
Genes and gene-environment interactions play important roles in the causation, pathogenesis, and prognosis of CVD (26, 27). Thus, knowledge of the spectrum of inherited susceptibilities to CVD, and elucidation of the patterns of inheritance for specific genetic abnormalities may provide improvements in early detection, risk stratification, and prevention of CVD in individual patients and their family members (26–29). Additionally, advances in pharmacogenomics provide an opportunity for improving disease treatment and response (30, 31).
A wide spectrum of CVD with inherited genetic susceptibilities is now known and the advances made over the last 25 years in understanding the genetic basis of these disorders provide a rationale for ensuring competence in genetics for experts in the prevention of cardiovascular diseases (32–34) The limitations of current genetic information in patient care, and the gaps between knowledge of an apparently inherited susceptibility and the availability of, or access to, corresponding effective treatments must be explicitly acknowledged (35). Finally, the benefits, risks, and costs associated with knowledge of a patient's genetic susceptibility to CVD and the ethical implications of referral for genetic testing and counseling must be recognized (36, 37).
Psychosocial factors add a significant dimension to CVD development and outcomes (38–43). Psychosocial factors influence the pathophysiology of disease, access to health care services, and adherence to treatment (44, 45). The best treatments are of no use to a patient if they cannot access the health care system, have inadequate services, or obtain health care too late to change the outcome (46–50).
Prospective cohort studies provide evidence for a role for depression, stress, psychosocial work characteristics, social isolation and support, and possibly hostility, as factors in the etiology of CVD and prognosis after CVD diagnosis (38–43). Over 30% of all patients with diagnosed cardiovascular or cerebrovascular disease have either clinical depression, anxiety, or other psychologically adverse conditions (40, 41). Depression is common overall, and risk is increased following a CVD event (39, 41, 43). Depression is a risk factor for coronary heart disease (CHD), recurrent CHD events, and heart failure (HF), and is associated with poor outcomes in CVD, post-coronary bypass, and HF. Socioeconomic factors, such as education, occupation, income and insurance status have a significant impact on risk factor development and CVD and mortality (38, 51–55).
All physicians and other health care providers should be able to diagnose anxiety and depression, and this should be routine after a CVD event or stroke (41). While psychological and medical interventions to treat depression and anxiety have not been shown to reduce future cardiac events to date, further research is underway to determine if outcomes after CVD events are benefited with treatment (41, 46, 47, 50, 56). Cardiac rehabilitation programs which incorporate psychosocial screening and intervention can improve treatment outcomes, the quality of life, and adherence of patients with psychological disorders (49, 57).
The assessment of both traditional and non-traditional risk factors underlies the primary and secondary prevention of CVD. Novel biomarkers are emerging as prognostic tools for CVD risk assessment. Persons with chronic kidney disease are considered to be a CHD risk equivalent by some guidelines (58, 59). The doses of many cardiovascular medications need to be adjusted in persons with chronic kidney disease, especially as glomerular filtration rate (GFR) declines and chronic kidney disease worsens.
Adults with inflammatory diseases such as lupus, psoriasis, or rheumatoid arthritis seem to be prone to accelerated atherothrombotic vascular disease (60, 61). Health care providers need to be more aggressive in trying to motivate patients with chronic kidney disease or inflammatory disorders to optimize their lifestyle habits and to achieve optimal levels of blood pressure and lipids. A number of ongoing studies are trying to assess the role of chronically high levels of inflammation in the development of CVD. Persons with lupus may also need to be screened for a prothrombotic state.
Recent studies have also shown that acute myocardial infarction rates and cardiovascular risk factors are increased in person with human immunodeficiency virus (HIV) infection as compared to non-HIV patients (62, 63). Certain classes of antiretroviral drugs, especially protease inhibitors, appear to promote dyslipidemia and may independently increase risk via inflammatory pathways (64). Strategies to reduce risk for atherosclerotic vascular disease should be incorporated into the standard care of HIV infection.
There is considerable research going on that is dealing with the prognostic role of biomarkers in persons with renal, inflammatory, or chronic infectious disease in both the primary and secondary prevention settings. In future years we will have a better understanding of when measurement of biomarkers such as C-reactive protein, B-natriuretic peptide, and urinary microalbumin should change standard clinical management and the intensity of risk factor modification (65–67).
The pre-clinical detection of atherosclerosis is an area of growing interest. The concept is to detect lesions in the cerebral, coronary, or peripheral vasculature before symptoms of end-organ ischemia occur (transient ischemic attack/stroke, angina/myocardial infarction (MI), claudication/limb ischemia), or before rupture and bleeding (aortic aneurysm) (68–70). Two recent studies from the MESA (Multi-Ethnic Study of Atherosclerosis) trial have clearly documented the prognostic power of elevated coronary calcium scores (71, 72). Such patients could be targeted for intensive risk factor control, other medical interventions, and endovascular or surgical treatments if indicated.
While the concept of preclinical detection is appealing for several reasons, controversy exists about the usefulness and efficacy of some screening programs and paradigms. The preventive cardiovascular specialist should have the knowledge base and skills to 1) advise patients about the usefulness of such screening including costs, 2) interpret the results of a screening test in terms of formulating a care plan, and 3) provide guidance about the need for subsequent testing and therapy.
Some screening approaches entail financial as well as potential medical risks, particularly if a positive test leads to further investigations and in some cases medical, surgical, or endovascular interventions. Thus it is important to have some guidance about what competencies are needed in these areas.
Adherence is a measure of how consistently a patient follows the specific requirements of an intervention. Knowledge about how to achieve a superior level of adherence is crucial. While the true rate of patient adherence is difficult to measure without using sophisticated tools that in themselves may influence patient behaviors, research generally indicates that long term adherence to behavioral and medical intervention may be as low as 50% (89). Nevertheless, in some settings and in some patients much higher rates of adherence occur suggesting that low rates of adherence result from specific causal factors such as the cost of medications, depression, or low health literacy, and that adherence is amenable to change. Some personal factors such as personality traits do not consistently influence adherence while others such as self efficacy do. Societal, health care system, and provider factors likely influence adherence rates (90–92). Successful prevention often requires life long actions by the patient and therefore a high level of long-term adherence is very important to effective prevention (93).
Disease outcome or management programs usually consist of at least two program elements: a patient monitoring component and a system to respond proactively to changes in the patient's symptoms or physical status. Effective disease management programs should reduce or delay the adverse consequences of chronic CVD events such as preventing or reducing the number HF hospitalizations in patients with HF and reduce the episodic nature of health care based on the treatment of acute episodes (94). The long term efficacy of most disease programs is uncertain. Since many patients have several chronic illnesses or complex prevention problems, the concepts underlying disease outcome interdisciplinary programs may in the future be applied to a wider set of prevention problems. Both adherence and disease outcome management programs are based on the integration of biologically derived scientific concepts with behavioral and social science concepts.
Many of the conditions and disease states that affect atherosclerotic risk can be prevented or at least modified by dietary interventions. These conditions and diseases include obesity and excess body weight, hypertension, lipid abnormalities, and diabetes. Even when conditions such as hypertension and hyperlipidemia are established and require pharmacologic therapy, dietary manipulations can reduce the dosage of medication required to achieve therapeutic goals. Similarly some nutritional supplements (e.g. red rice yeast (98) and omega 3 fatty acids (99)) contain pharmacologically active substances that can be used therapeutically in selected patients. In contrast, some dietary and nutritional supplements may contain substances such as sympathomimetics that increase cardiac arrhythmias. Consequently, healthcare providers practicing preventive cardiology must be required to have an understanding of nutrition and the principles of nutrition so that they are able to provide expert advice to patients and to reinforce expert advice given by nutritional professionals. In addition, credibility as a preventive specialist with patients is enhanced when the preventive cardiologist is conversant in the basics of diets and nutritional therapy.
The management of dyslipidemia has emerged as a key therapeutic strategy to reduce both primary and secondary cardiovascular events. Despite a plethora of large outcome trials (110–112) supporting the evidence for lipid-altering treatments to improve outcomes and national guidelines that have established specific goals of treatment, there remains a significant treatment gap in the achievement of low-density lipoprotein cholesterol (LDL-C), non-HDL-C, and HDL-C targets (113, 114). The National Cholesterol Education Program ATP III (NCEP ATP III) Guidelines (115) updated in 2004 (116) mandate an LDL-C goal for high-risk patients of less than 100 milligrams per deciliter with an optional goal of less than 70 milligrams per deciliter for patients with CVD plus diabetes or other multiple risk factors. The AHA Secondary Prevention Guidelines also advocate an LDL-C goal and non-HDL-C goal of less than 70 milligrams per deciliter and less than 100 milligrams per deciliter, respectively (17). Yet, recent surveys demonstrate that less than one-third of patients with CVD with additional risk factors are achieving these recommended targets (113). In addition, patients with low HDL-C and/or elevated triglycerides remain at elevated residual risk even at recommended LDL-C goals (117–119).
Atherothrombosis is a progressive process that includes atherosclerotic plaque formation, disruption, and thrombosis. These processes constitute the pathophysiology that underlies acute coronary syndrome, ischemic stroke or transient ischemic attack, and PAD. United States prevalence data lists 7.2 million people affected by MI, 6.5 million with angina pectoris, 5.5 million with stroke (120), with 8 to 12 million people affected by PAD (121). The Adult Treatment Panel III of the National Cholesterol Education program considered PAD to be a CHD risk equivalent (115). The recently published REACH registry (REduction of Atherothrombosis for Continued Health) showed that among patients with symptomatic atherothrombosis, 16% had symptomatic polyvascular disease (122). Approximately 56% of stroke patients 60 years and older have coexisting CAD and evidence suggests the 20% to 40% of patients with ischemic stroke or transient ischemic attack concurrently have silent CAD (123, 124).
Hypertension is a major contributor to the global disease burden and is one of the leading preventable causes of premature death worldwide (134). In the United States, a disproportionate burden of hypertension and its associated complications, including CHD, HF, stroke, and end-stage renal disease and CVD mortality, affect African Americans (also referred to as US Blacks) (135). Preventive cardiovascular specialists should have knowledge of hypertension and mechanisms of elevated blood pressure, and understanding of the therapeutic lifestyle changes and pharmacologic interventions that are crucial for controlling hypertension in clinical practice. A basic knowledge of the potential mechanisms of elevated blood pressure and associated risk factors is necessary to understand the ongoing research into new approaches for prevention, identification and therapy. A basic understanding of the use of therapeutic lifestyle changes and appropriate drug therapies for patients with compelling indications is necessary to reduce cardiovascular morbidity and mortality.
Smoking remains the most important risk factor for CVD in the world (137, 138). It is estimated that 40% of all heart disease is related to smoking (139, 140). The biochemical and physiological consequences of smoking on CVD are well defined (139, 141, 142). Compelling evidence exists demonstrating that smoking cessation is associated with significant reversal of risk for CAD, stroke, and cancer related deaths (137). In addition, there are multiple societal consequences from cigarette smoking including enormous economic costs. In the United States alone, it is estimated that smoking costs $167 billion each year (137). Since 1965, smoking in the United States has declined by 47% among people over the age of 18. However, it is estimated that over 23% of adult men and 19% of adult women continue to smoke and this number is rising in the young (137). In addition, exposure to second hand smoke places significantly more persons at risk for heart disease and stroke (143, 144).
Clinical competency in smoking cessation treatment is critical for those whose expertise encompasses primary and secondary prevention of CVD and stroke. Clinical competency includes skills in patient education, counseling, and behavioral change, and knowledge of important pharmacotherapies, including risks and benefits. Clinical competency relies on the identification of smoking status in all patients, prompt and definitive advice to quit, and the implementation of smoking cessation counseling and pharmacotherapies. Systematic follow-up of all smokers at subsequent visits and the involvement of health care professionals with smoking cessation expertise improves life time smoking cessation.
Obesity is a disease that is reaching epidemic proportions, not only in the United States, but elsewhere throughout the world. At the present time, greater than 60% of the United States adult population is classified as either overweight or obese (160, 161). In addition, childhood obesity is growing in an alarming fashion. Overweight and obesity are particularly prevalent in certain minority groups and in individuals of lower socio-economic status. Overweight is defined as a body mass index of 25 to 29.9 kg/m2, and obesity as a body mass index greater than 30 kg/m2 (162). Higher body weight is associated with an increased risk of hypertension, hyperlipidemia, stroke, CAD, insulin resistance and type 2 diabetes mellitus. Moderate weight loss has been shown to decrease the severity of these comorbidities, and data from observational studies suggests a concomitant decrease in mortality (163, 164).
Overweight and obesity are felt to result from an imbalance between energy intake and expenditure. Less than 20% of American adults regularly engage in moderate physical activity. The AHA identified an “epidemiological triad” in Prevention Conference VII (November 2004), which includes host factors (genetic make up, age/gender, attitudes and behavior), vectors for increased energy consumption or decreased energy expenditure (i.e. automobile travel instead of walking or biking, large portion sizes, high fat and high calorie foods), and environmental factors (i.e. cost of goods, government policy, as well as socio-cultural forces). They suggest that all components need to be addressed in order for successful prevention to occur (165).
A variety of behavioral options exist to manage overweight and obesity effectively, which include dietary therapy, physical activity, and behavioral techniques. To be successful in achieving long-term weight maintenance, however, these methods have to be individually applied to each patient in the context of regular and consistent medical supervision. Reduction of initial body weight by only 5% to 10% has been shown to result in significant cardiovascular risk factor reduction (166), as well as a variety of other health benefits. Presently, training on overweight/obesity in specialty and subspecialty medical education is woefully inadequate.
Important goals of exercise-based cardiac rehabilitation are to stabilize existing atherosclerotic plaques, improve endothelial function and lessen arterial inflammation by modulating lipid/lipoprotein levels and blood pressure, and achieve smoking cessation, if appropriate (169, 170). Additional objectives are to: increase functional capacity, decrease symptoms, reduce body weight and fat stores, promote psychosocial well-being, and improve the ability of the patient to return to work (171, 172). Recent meta-analyses indicate that exercise-based cardiac rehabilitation improves the cardiovascular risk factor profile and reduces all-cause and cardiovascular mortality, and that these benefits persist in the current era of cardiovascular therapeutics (173).
In the past, only post-MI patients were considered candidates for exercise-based cardiac rehabilitation. However, the proven benefits and safety of this intervention have expanded to include patients with angina, diabetes or metabolic syndrome, cardiomyopathy, pacemakers, heart valve replacement, concomitant pulmonary disease, cardiac transplant, and HF, as well as patients who have undergone percutaneous coronary intervention or coronary artery bypass graft surgery (170, 171, 174), yet these diagnoses are not all covered by health insurance.
Moderate-to-vigorous physical activity and improved cardiorespiratory fitness reduce cardiovascular-associated morbidity and mortality by multiple mechanisms (168, 174), including antiatherosclerotic, anti-ischemic, antiarrhythmic, and antithrombotic effects. Each 1 metabolic equivalent (MET), (1 MET = 3.5 mL O2/kg/min) increase in exercise capacity appears to confer an 8% to 17% reduction in mortality (175). Alternatively, an approximate 1,000-kcal/week increase in activity confers the equivalent survival benefit that would accrue by increasing cardiorespiratory fitness by 1 MET (176). Exercise testing may be helpful in quantifying aerobic capacity and in establishing a safe and effective exercise prescription (177, 178).
There are very strong epidemiological data available to support the concept that type 2 diabetes is associated with greatly increased risk of cardiovascular events. In addition, patients with type 1 diabetes of long duration, with other complications, are also at risk for cardiovascular events. Several clinical trials have assessed the effect of glycemic control on long-term microvascular complications, including CVD. Good glycemic control utilizing effective insulin regimens in type 1 diabetes may prevent CVD and trials of the effect of intensive therapy on CVD in type 2 diabetes are in progress. The metabolic syndrome, pre-diabetes, and insulin resistance, also portend an elevated risk of cardiovascular disease.
Patient-specific and systems approaches to the primary and secondary prevention of CVD are essential for optimal atherosclerosis disease management (191–193). This type of approach must encompass a simple and meaningful strategy for both patient and provider throughout the process of risk assessment and intervention (medication management and lifestyle modification) (194). Guidelines are based on the results of randomized trials (17).
Too often providers forget to implement the standard guidelines that deal with antiplatelet therapy, antihypertensive therapy, lipid lowering therapy, and lifestyle changes; all of these items are important in improving the quality of medical care. As a profession, we need to improve the frequency with which evidence-based guidelines are applied in clinical practice. Many guidelines have been published but there has been a disappointing lack of standard implementation.
Basic physician education and passive dissemination of guidelines alone are generally insufficient to sustain quality improvement. Chart audit and feedback of results, reminder systems to consider use of specific medicines or tests, and the use of local opinion leaders have had variable results. Multifactorial interventions that simultaneously attack different barriers to change tend to be more successful than isolated efforts. Dissemination of practice guidelines and knowledge of cardiovascular prevention must be accompanied by more intensive educational and behavioral interventions to maximize the chances of improving physician practice patterns.
The AHA has endorsed the Get With the Guidelines approach and the ACCF has endorsed an approach to the management of chronic stable angina and the prevention of CVD in general (192, 195). These approaches should help medical practices and the individual patient better understand the various pharmacologic therapies available for a given individual condition.
The ACCF Guidelines Applied in Practice (GAP) Program is also a well conceived systems approach that has been focused on patients presenting with acute coronary syndromes (196–198). The same principles of prompt initiation of antiplatelet therapy, beta blockade, inhibition of the renin-aldosterone-angiotensin system, cholesterol lowering therapy, and better dietary and exercise habits can also be modified for use in chronic management of persons with atherosclerotic vascular disease (199–201).
Existing patient specific, systems approaches to prevention of CVD including:
This document was approved by the American College of Cardiology Board of Trustees in October 2008, and by the American Heart Association Science Advisory and Coordinating Committee in November 2008, and by the American College of Physicians in April 2009.
The American College of Cardiology Foundation requests that this document be cited as follows: Bairez Merz CN, Alberts MJ, Balady GJ, Ballantyne CM, Berra K, Black HR, Blumenthal RS, Davidson MH, Fazio SB, Ferdinand KC, Fine LJ, Fonseca V, Franklin BA, McBride PE, Mensah GA, Merli GJ, O'Gara PT, Thompson PD, Underberg JA. ACCF/AHA/ACP competence and training statement: a curriculum on prevention of cardiovascular disease: a report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence (ACC/AHA/ACP Committee on Prevention of Cardiovascular Disease); J Am Coll Cardiol 2009;VOL:page-page.
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