‘ABCDE’ makes an effective prevention tool

Approach translates guidelines into a comprehensive management plan for the primary and secondary prevention of CVD.

The Cardiology Evidence Base, whatever its gaps and shortcomings, is arguably the deepest and highest-quality evidence base available to any medical specialty.

Clinicians can face the challenges of the human burden and financial cost of heart disease armed with this formidable body of knowledge.

Translating the available data from words on a journal page into a concrete plan of action for any single patient under our care is still a challenge. Guidelines from the American Heart Association and American College of Cardiology sift, condense and analyze the clinical trial results into state-of-the-art consensus recommendations for the delivery of the best care for CVD.

Of course, no guideline statement can replace the role of an informed and talented clinician in shaping the application of the evidence to the individual patient seated in the examination room. These consensus guidelines represent the best available combination of data and expert opinion in guiding the care of the population as a whole.

Roger S. Blumenthal

The forefront of cardiovascular research and our evidence base are moving forward at an impressive and satisfying rate. While the leading edge marches ahead, the tail — the large group of Americans with CVD who are receiving incomplete or inadequate therapy — remains woefully mired in suboptimal care. Our patients stand to gain a great deal by simply focusing on applying the lessons we have already learned in a more consistent manner.

Addressing the gap

This gap between guidelines and delivery of care has been recognized for some years. An analysis of the National Registry of MI database from 1994 to 2000 found that only 77% of patients hospitalized for MI received simple aspirin therapy at discharge. Even as recently as 2002, rates of self-reported aspirin use in patients with CAD hovered at 80%. Disturbingly, only 60% reported receiving ongoing lipid-modifying therapy.

Much of the effort undertaken to address these short-fallings has taken the form of top-down, externally-driven initiatives, such as pay-for-performance incentives and public benchmarking of individual and institutional adherence to guidelines. Although, undoubtedly, these sorts of system-wide reforms stand to play a significant role in enhancing our overall quality of care, there has been relatively little focus on cognitive and practical interventions at the practitioner level.

We propose a simplified “ABCDE” guideline structure that both emphasizes the cornerstone principles of state-of-the-art cardiovascular prevention and refocuses the understanding of CVD as a continuum of disease from risk factors to vascular events.

A common pitfall in care, particularly by non-CVD specialists, is the failure to view atherosclerotic heart disease as a systemic disease carried forward by multiple common risk factors. Our attention and efforts are largely driven by the acute events that mark the progression of disease, the infarcts and strokes, to the point of losing focus on care of the underlying processes driving the disease. This is precisely the point missed in the widespread public perception, unfortunately still held by some physicians, that stents and bypass surgery cure or clean out heart disease. Prompt revascularization is helpful when an acute coronary syndrome develops, but it is the life-long attention to that patient’s hypertension, lipids, weight, dietary habits and tobacco use that will serve them the best in the long run. The recent results from COURAGE underscore the fundamental importance of these disease-modifying therapies in the treatment of atherosclerosis and its consequences.

Simple as ABC

The “ABCDE” approach simplifies and systematizes lengthy and complex guidelines into a comprehensive management plan for the primary and secondary prevention of CVD:

• A: Antiplatelet therapy.
• B: BP control.
• C: Cholesterol-lowering therapy and cigarette cessation.
• D: Diet modification and diabetes — prevention of or management of the condition.
• E: Exercise.

Initially introduced as a summary framework to guide care in the preventive cardiology center setting, we believe that this algorithm can be an effective and efficient intervention each time a patient with or at risk for atherosclerotic heart disease makes contact with the medical system.

Application of this approach by cardiovascular care providers of all stripes, whether by the nurse in an ICD follow-up visit, the physiologist in cardiac rehabilitation or a vascular surgeon, would guarantee multiple layers of redundancy and cross-checking. It also serves the educational purpose of reinforcing the fundamental importance of aggressive risk factor modification in every patient undergoing other therapies for consequences of their heart disease.

The “ABCDE” framework provides a simplified structure to enhance adherence to guideline-based therapy and ensure the delivery of the best available care to our patients. Whether applied as a guide to prescription of therapy de novo or as a checklist to evaluate ongoing treatment, this is a systematic and transparent method to broaden the reach of the cornerstone therapies for CVD and its prevention.

Chris Sibley, MD, is a Fellow at the Johns Hopkins Ciccarone Center for Prevention of Heart Disease. Juan Rivera, MD, is a Fellow at the Johns Hopkins Ciccarone Center for Prevention of Heart Disease and a member of the Today in Cardiology Fellows Advisory Board. Roger S. Blumenthal, MD, is the Director of the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease and a Member of the Preventive Cardiology Section of the Today in Cardiology Editorial Board.

For more information:

• Spencer FA, Meyer TE, Gore JM, Goldberg RJ. Heterogeneity in the management and outcomes of patients with acute MI complicated by heart failure: the National Registry of Myocardial Infarction. Circulation. 2002;105:2605-2610.
• Newby LK, LaPointe NM, Chen AY, et al. Long-term adherence to evidence-based secondary prevention therapies in coronary artery disease. Circulation 2006;113:203-212.
• Associated Press. Philbin says he’ll have bypass surgery. March 12, 2007.