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New Measures Improve Heart Care
Date:11/4/2007

Programs that simplified treatment choices led to better outcomes, research shows

SUNDAY, Nov. 4 (HealthDay News) -- Simplify. Simplify. Simplify.

New research shows this mantra works when it comes to controlling high blood pressure, which is the leading risk factor for premature death worldwide.

A streamlined, "back to the future" approach to treating hypertension helped more patients control their blood pressure than did working with often confusing national guidelines, according to a Canadian study released Sunday at the American Heart Association (AHA) annual meeting in Orlando, Fla.

"This algorithm does result in better blood-pressure control in primary-care settings and, further, it is possible that this protocol or protocols like it may be a paradigm for a range of chronic diseases associated with poor control, especially those associated with risk factors for heart attack and stroke," said study author Dr. Ross D. Feldman, the R.W. Gunton Professor of Therapeutics at the University of Western Ontario.

"Based on the results, this is a very handy algorithm. It's very useful," added Dr. Sidney Smith, past president of the AHA and director of the Center for Cardiovascular Science and Medicine at the University of North Carolina School of Medicine. "But always when you have a clinical trial, adherence rates are higher so it's important to look at this in a real-world setting."

Feldman added: "It's absolutely clear that we're facing an increasing global epidemic of hypertension. On the one hand, it's easy to diagnose and we have many effective treatments, yet in North America and worldwide, only one in three patients have their high blood pressure controlled."

During the first year after diagnosis, only about 50 percent of patients take their drugs and compliance falls off further after that. And a lot of this can be attributed to highly complex prescribing regimens of multiple drugs, adding drugs, switching drugs and more. The end result -- "therapeutic inertia."

The STITCH (Simplified Therapeutic Intervention to Control Hypertension) trial, funded by Pfizer Inc., involved introducing a simplified, four-step algorithm to 45 family practices in southwestern Ontario and comparing that with guidelines-based care, which can involve dozens of choices for doctors to sort through. The new protocol is not dissimilar to strategies employed in the 1960s.

In the STITCH group, 65 percent of patients reduced their blood pressure to the target level, compared with 53 percent in the guidelines group, a 12 percent absolute change in the proportion of patients who managed to control their hypertension.

While this trial involved mainly single-doctor practices, "the real impact of this study would not be in single practices but with the incorporation of the practices into health-care networks," Feldman noted.

A second study presented at the meeting, and also appearing in the Nov. 28 issue of the Journal of the American Medical Association, found that a statewide program in North Carolina cut the time it took to treat patients having a heart attack either with clot-busting drugs or percutaneous coronary intervention (PCI, also known as angioplasty) by up to 32 minutes.

With a heart attack, the sooner the patient's blocked arteries can be reopened, restoring blood flow to the heart, the better. AHA/American College of Cardiology guidelines recommend that drugs be delivered within 30 minutes and PCI accomplished with 90 minutes of the patient entering the hospital door (known as "door-to-balloon" time).

This program involved improvements such as naming a nurse coordinator and establishing a single telephone number to activate the catheterization lab team, at 65 hospitals throughout the state.

At hospitals that offered PCI, the percentage of patients receiving clot-busting therapy within half an hour improved from 35 percent to 52 percent.

Door-to-balloon times improved from 85 minutes to 74 minutes at PCI hospitals. After the program was established, 72 percent of patients received PCI within 90 minutes.

For patients transferred from a non-PCI hospital to a PCI hospital, door-to-balloon times fell from 160 minutes to 128 minutes, and to 106 minutes for hospitals that routinely transferred for PCI.

Mortality rates were not lowered but the study was not sufficiently powered to see this possible effect, noted study senior author Dr. Christopher B. Granger, director of the cardiac care unit at Duke University Medical Center.

"This is the largest regional STEMI [ST-segment-elevation myocardial infarction] reperfusion system in the U.S.," Granger said. "All of the key times were significantly improved. It shows that application of reperfusion on a large scale is possible and should be a high national priority."

Disappointingly, a third study being presented at the meeting found that teaching self-management skills to heart failure patients brought no additional benefit over enhanced patient education.

However, study co-author Dr. James E. Calvin, of Rush University Medical Center in Chicago, said that "in the patients with the poorest functional capacity [who received both training in self-management skills and education], you can see that there's a significant risk reduction for... death and heart failure hospitalization. Treatment may work in patients who need it."

More information

Visit the American Heart Association for more on high blood pressure.



SOURCES: Sidney Smith, M.D., past president, American Heart Association, professor, medicine, and director, Center for Cardiovascular Science and Medicine, University of North Carolina School of Medicine, Chapel Hill; Nov. 4, 2007, news conference with Ross D. Feldman, M.D., R.W. Gunton Professor of Therapeutics, University of Western Ontario, London, Canada; Christopher B. Granger, M.D., professor, medicine, and director, cardiac care unit, Duke University Medical Center, Durham, N.C.; James E. Calvin, M.D., Rush University Medical Center, Chicago; Nov. 28, 2007, Journal of the American Medical Association


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