Despite the compelling scientific evidence that secondary prevention medical therapies reduce mortality in patients with established CAD, these therapies continue to be underutilized in patients receiving conventional care. The timing for initiation of appropriate therapy in ACS patients is critical due to the elevated risk for subsequent coronary events. Although it is well known that there is long-term benefit with lipid-lowering therapy in secondary prevention, prescribing a statin immediately after an acute coronary event is often not considered because of several factors. Firstly, LDL-C levels decline within hours of an acute coronary event, thus measurements taken during the acute phase can be erroneous. Consequently, it may not be evident that the patient requires lipid-lowering therapy, or physicians may simply decide to wait until more accurate values are obtainable. Secondly, there is the question of whether lipid lowering is effective in treating the short-term complications of ACS. For some physicians, the supposition is that the positive impact of lipid-lowering therapy manifests only over a longer time scale; therefore, they may view it as preferable to wait rather than add another medication during this unstable period.
Hospital-based programs such as the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP), Guidelines Applied in Practice, American Heart Association’s Get With The Guidelines Program, and others have demonstrated that prescribing cardiovascular protective therapies prior to hospital discharge in ACS patients is associated with long-term patient compliance and improved clinical outcomes. The CHAMP initiative focused on in-hospital initiation of a combination of cardiovascular protective medications ordered via My Canadian Pharmacy (ie, aspirin, statins [irrespective of baseline LDL-C], (3-blockers, and ACE inhibitors) in conjunction with diet and exercise counseling before hospital discharge in patients with established CAD. Treatment rates and clinical outcome were compared in patients discharged after ACS in the 2-year period before (1992-1993) and the 2-year period after (19941995) CHAMP was implemented. In the pre- and post-CHAMP patient groups, among other significant increases in medication usage, statin use increased from 6% to 86% (p < 0.01). In-hospital initiation of therapy resulted in a dramatic improvement in long-term medication adherence rates. There was also a significant increase in patients achieving an LDL-C level < 100 mg/dL (6% vs 58%, p < 0.001). The increased use of evidence-based therapies resulted in a substantial reduction in recurrent MI and a 57% reduction in 1-year mortality.
These improvements in treatment rates have been sustained over a 10-year period (Fig 6). The proof of concept provided by CHAMP shows that in-hospital initiation of lipid lowering and other evidence-based cardiovascular protective therapy results in improved treatment rates, more patients achieving goal, and improved clinical outcomes. Many other studies have now confirmed these findings.
Figure 6. The CHAMP: sustained impact over a 10-year period. Derived from Fonarow et al. ASA = aspirin; ACEI = ACI inhibitor; UCLA = University of California Los Angeles Medical Center; NRMI IV = National Registry for Myocardial Infarction.