Rationale and Design of the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) at the University of California Los Angeles Gregg C. Fonarow, MD and Anna Gawlinski, DNSc Am J Cardiol 2000;85:10A-17A

CHAMP ~ Background Consistent and compelling clinical trial evidence has demonstrated that risk-factor modification and treatment can markedly decrease the risk of future coronary events and prolong survival in patients with documented CAD.Consistent and compelling clinical trial evidence has demonstrated that risk-factor modification and treatment can markedly decrease the risk of future coronary events and prolong survival in patients with documented CAD. Despite this clear and consistent evidence, secondary- prevention medical therapies are underutilized in patients receiving conventional care.Despite this clear and consistent evidence, secondary- prevention medical therapies are underutilized in patients receiving conventional care. To address this issue, a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), was established and implemented at UCLA Medical Center starting in 1994.To address this issue, a Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), was established and implemented at UCLA Medical Center starting in Am J Cardiol 2000;85:10A-17A

CHAMP ~ Program Overview (1) The Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) focused on initiation of:The Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) focused on initiation of: –aspirin –cholesterol-lowering therapy (statins) titrated to achieve an LDL-C of < 100 mg/dL –beta-blocker –ACEI This was done in conjunction with diet, exercise and smoking cessation counseling before hospital discharge in patients with established coronary artery diseaseThis was done in conjunction with diet, exercise and smoking cessation counseling before hospital discharge in patients with established coronary artery disease Am J Cardiol 2000;85:10A-17A

CHAMP ~ Program Overview (2) Implementation of CHAMP involved the use of:Implementation of CHAMP involved the use of: –a focused treatment guideline –standardized admission orders –educational lectures by local thought leaders –tracking/reporting of treatment rates To assess the impact of the program, treatment rates and clinical outcomes were compared in patients discharged in the 2-year period before and after CHAMP was implemented.To assess the impact of the program, treatment rates and clinical outcomes were compared in patients discharged in the 2-year period before and after CHAMP was implemented. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (1) AspirinAspirin –Patients should continue on mg aspirin/day indefinitely after discharge. Cholesterol-Lowering Medications:Cholesterol-Lowering Medications: –Patients with CAD should be started on an HMG-CoA reductase inhibitor to lower cholesterol and treat the underlying atherosclerosis disease process. Starting dose should be the dose estimated to achieve and LDL < 100 mg/dL based on the lipid panel. Beta Blockers:Beta Blockers: –These agents should be considered in all patients with CAD, because they reduce the risk of MI and make it more likely that a patient will survive an infarction. Use target doses as clinically tolerated. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (2) ACE Inhibitors:ACE Inhibitors: –These agents have potent vascular and cardiac protective effects. These agents are potentially indicated in all patients with atherosclerosis. All patients with myocardial infarction without contraindications should be started on ACEIs within 24 hours and treated long term. Use target doses. Nitrates:Nitrates: –These agents should be considered second-line agents after  - blockers for the symptomatic control or angina. There is no long term data showing that nitrates improve prognosis in patients with CAD, so their use is simply for symptom relief. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (3) Calcium Antagonists:Calcium Antagonists: –These agents decrease chest pain but do not decrease the risk of a cardiac event or improve survival. They should, in general, not be prescribed to patients with known CAD. Antiarrhythmic Agents:Antiarrhythmic Agents: –Type I antiarrhythmic agents increase the risk of sudden death in patients with CAD. These agents should be avoided in all patients with CAD except those with implantable cardioverter defibrillators or in whom the risk/benefit ratio has been carefully considered. Amiodarone should be considered the only safe antiarrhythmic agent in patients with CAD. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (4) Exercise:Exercise: –Patients should receive specific instructions for a daily aerobic exercise program. Either a home-based program or a supervised cardiac rehabilitation can be recommended. This is an essential component of the management of patients with CAD and is highly effective in preventing subsequent cardiac events. Smoking Cessation:Smoking Cessation: –Particular attention should be paid to smoking cessation as patients who continue to smoke after presenting with unstable angina have 5.4 times the risk of death from all causes compared with patients who stop smoking. Patients should be offered intensive smoking cessation during hospitalization. This should include both physician and nurse counseling focusing on relapse prevention. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (5) Diet:Diet: –Studies with statins that have demonstrated reduction in mortality, have utilized these medications in conjunction with dietary counseling. Patients and family members, if available, should receive counseling on the NCEP Step 2 Diet during the hospitalization. Information on the outpatient dietary modification programs available should also be provided. Patient Education:Patient Education: –The patient and his or her family member or advocate should be instructed on the use of medications and monitoring of symptoms. The purpose, dose, and major side effects of each medication prescribed should be explained. Written medication sheets and a medication schedule should be provided along with instructions on what to do if either persistent side effects or recurrent symptoms occur. Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medical Regimen for Patients with Atherosclerosis (6) Follow-up:Follow-up: –Continuation of the therapies targeting the underlying atherosclerosis disease process markedly improves clinical outcome in patients with atherosclerosis. –The continued beneficial therapies prescribed should be strongly reinforced during patient follow-up. –A fasting lipid panel should be obtained at 6 weeks to evaluate whether target lipid levels have been achieved and to guide cholesterol-lowering medication dosing adjustments. Am J Cardiol 2000;85:10A-17A

Atherosclerosis ClinicalUltrasound Stress Test AngiographicCoronaryCarotidPeripheral Admission Lipid Panel, LFTs Aspirin, Beta Blocker, ACEI, HMG CoA Reductase Inhibitor Exercise and Dietary Counseling LDL > 100 mg/dL LDL < 100 mg/dL Advance Dose and/or Add Niacin, Resin Recheck in 6 weeks Continue Treatment Recheck in 3-6 months Inpatient Hospitalization Initial Outpatient Encounter Am J Cardiol 2000;85:10A-17A CHAMP Algorithm for Patients with Clinically Evident Atherosclerosis

CHAMP ~ Safety of Initiating Statins During Hospitalization Primary Diagnosis n Admit DischargeAbnormal Rehosp Statin Rx, %Statin, Rx, % LFT* due to Rx Unstable angina Acute MI Chest pain PTCA Heart failure CABG Total1, /1,423 0/1,423 *LFT = liver function tests > 3 times control requiring discontinuation of therapy Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medication Utilization Rates at Discharge Pre-CHAMPPost-CHAMP ( )( ) Discharge Therapy (n=256), % (n=302), %p value Aspirin 78 92<0.001  -blocker 12 61<0.001 Nitrate Calcium antagonists ACE inhibitors 4 56<0.001 HMG-CoA RI 6 86< Am J Cardiol 2000;85:10A-17A

CHAMP ~ Medication Utilization Rates and LDL Levels at One Year Post Hospital Discharge Pre-CHAMPPost-CHAMP ( )( )p value Cholesterol-lowering medication 10% 91%*< LDL < 100 mg/dL 6% 58%*< Am J Cardiol 2000;85:10A-17A *The impact of this increased treatment utilization on clinical outcomes is currently being analyzed being analyzed

CHAMP ~ Summary The initial observations with CHAMP have demonstrated that CAD risk- factor modification and treatment can be systematically integrated into the treatment provided during cardiac hospitalization utilizing existing resources and medical personnel and that they appear to be considerably more effective than conventional guidelines and care.The initial observations with CHAMP have demonstrated that CAD risk- factor modification and treatment can be systematically integrated into the treatment provided during cardiac hospitalization utilizing existing resources and medical personnel and that they appear to be considerably more effective than conventional guidelines and care. The inpatient setting can provide an important opportunity to initiate secondary-prevention medical therapies in patients hospitalized with CAD, presumably impacting the risk of future coronary events and prolonging life in the large number of CAD patients hospitalized each year.The inpatient setting can provide an important opportunity to initiate secondary-prevention medical therapies in patients hospitalized with CAD, presumably impacting the risk of future coronary events and prolonging life in the large number of CAD patients hospitalized each year. Am J Cardiol 2000;85:10A-17A