Neil F. Gordon, M.D., Ph.D., MPH

Medical Director, Center for Heart Disease Prevention

St. Joseph’s/Candler Health System

Savannah, Georgia, INTER_XVENT^USA

Unprecedented attention is being placed on cardiovascular disease prevention.  This focus on prevention has arisen for four major reasons in the United States.  These reasons are: escalating health care costs, publication of landmark clinical trials documenting the effectiveness of cardiovascular disease risk management interventions, implementation of quality assurance measures, and assumption of financial risk by physicians and hospitals for the health care of patients enrolled in capitated managed care plans.

It is widely believed that future health care systems will be built on “pillars of prevention.”  However, although sound clinical reasons exist for emphasizing prevention in day-to-day medical practice, studies indicate that physicians often fail to provide recommended cardiovascular disease risk management interventions.  Recent evidence has identified a large gap between recommended preventive therapies for persons with or at risk for cardiovascular disease and the care they are actually receiving.  This “treatment gap” remains a final frustrating impediment to fulfilling the potential for improving quality of life and prognosis through cardiovascular disease risk management interventions.

Clearly, there is an urgent need to bridge the treatment gap by developing and implementing approaches that provide all persons with or at risk for preventable forms of cardiovascular disease (especially atherosclerotic vascular disease) access to high-quality, cost-effective, long-term, comprehensive risk management services appropriate for their specific needs and personal circumstances.  It is recommended that these approaches be based on models shown to be effective in appropriately designed clinical trials.  In this manuscript, I briefly describe the key features of two such approaches we have successfully implemented in clinical and community-based settings.

Risk Management in Patients with Established

Atherosclerotic Cardiovascular Disease (Secondary Prevention)

Recent arteriographic, secondary prevention clinical trials have convincingly demonstrated the efficacy of aggressive cardiovascular disease risk factor modification.  Of the various studies performed to date, the Stanford Coronary Risk Intervention Project (SCRIP) is of particular relevance because it utilized what appears to be the most logical approach to risk management, namely, aggressive modification of multiple cardiovascular disease risk factors via comprehensive lifestyle intervention combined with appropriate pharmacotherapy.  Moreover, SCRIP employed a physician-supervised, nurse case manager model with consultation from other health care professionals that could be potentially implemented in a variety of settings.  In SCRIP, the multifactor risk management program reduced hospitalization for clinical cardiac events by 40% (p<0.05) versus usual care during the 4-year study period.

To determine the feasibility of implementing a comprehensive cardiovascular disease risk management program modeled after SCRIP outside of an academic research setting, we modified SCRIP protocols for use by a private practice cardiology group in collaboration with a hospital-based outpatient cardiac rehabilitation program in Dallas, Texas.  Based on our experiences with 367 consecutive patients enrolled in the risk management program in Dallas between November 1993 and February 1995, together with newer guidelines from authoritative organizations, the protocols were further revised.  In mid-August 1995, we implemented the risk management program in collaboration with a hospital-based outpatient cardiac rehabilitation program in Savannah, Georgia.  During the initial 20 months, 1016 new patients with or at high risk for atherosclerotic cardiovascular disease were enrolled in the program.

The basic approach to comprehensive cardiovascular disease risk management currently utilized at our center in Savannah for patients with established aterosclerotic cardiovascular disease is summarized in Figure 1.  The cardiovascular disease risk management action plan focuses on the interventions listed in Table 1, in accordance with published American Heart Association and American College of Cardiology guidelines.  Key components of the action plan are summarized in Table 2.