Q. Are lipid panels obtained in the hospital accurate?

A. Studies have shown that lipid panels obtained in the first 6-12 hours after the onset of acute myocardial infarction are reflective of the patient’s baseline steady state lipid levels.  At that time frame an acute phase response occurs, with a fall in total cholesterol levels and LDL cholesterol levels.  This can decrease LDL levels by as much as 50% below baseline values.  It can take 4 to 6 weeks for the levels to return to baseline.  Studies have shown that despite the fall in absolute levels of LDL, the acute phase response make LDL more prone to oxidation and HDL “proinflammatory”.  Patients are thus not protected from atherosclerosis during this time frame. A nonfasting lipid panel obtained on or shortly after admission can be used to assess the patients’ baseline lipid levels, diagnose lipoprotein disorders, and guide the statin starting dose.  Lipid profiles obtained 24 hours to 6 weeks after myocardial infarction onset or after CABG, should be interpreted know the LDL level may be as much as twice the measured value.

Q.  If patients with coronary artery disease and low or normal LDL levels benefit from statin treatment, why bother to check a baseline lipid level?

A. Studies have shown that patients with LDL cholesterols even in the range of 70 –130 mg/dl have a nonfatal cardiovascular event and mortality reduction with statin treatment.  Some have argued that knowing the patient has atherosclerosis is evidence enough for starting statin treatment.  One option is to initiate statin treatment in all patients without checking baseline levels.  At 6 weeks, when a lipid panel is obtained the dose of statin can be adjusted to achieve an LDL < 100 mg/dl.  Drawing an admission lipid panel dose have certain advantages.  Patients often like to know what their baseline lipid levels were before starting on treatment.  The baseline lipid level can help guide the dose of statin needed to reduce the LDL to < 100 mg/dl.  Patients with complex lipid disorders and be identified early so appropriate follow-up can be arranged.

Q. Are there benefits to the hospital if treatments rate improve?

A. There are a number of quality indicators that are in place or are being phased in that use of appropriate cardiac therapies.  The Joint Commission assesses measures such as use of aspirin, beta blockers, and ACE inhibitors in patients with acute myocardial infarction.  In addition NCQA measures are used by health plans and employer groups to see what medical groups and hospitals they want to contract with.  The measurement, evaluation and treatment of LDL after a cardiac hospitalization is one of the NCQA measures.  With the CHAMP program, length of stay and inpatient medical costs were reduced.  In addition UCLA Medical Center was noted to have one of the lowest risk adjusted mortality rates for acute myocardial infarction rates in the State of California after starting this program.  The Pacific Business Group on Health awarded UCLA Medical Center a Blue Ribbon Award for Excellence in 2000 for providing preventive care services for patients with high blood pressure and high cholesterol. This award was given to only 7 hospitals in the state, which UCLA being the only teaching hospital to be so commended. There are thus many benefits to the hospital to have a treatment program in place, beyond the knowledge that quality of care is being improved and long term mortality rates reduced.

Q.  How can we get a program going when the physicians at my hospital cannot seem to agree on anything?

A. Getting a team together to review the baseline treatment rates in your hospital can help to make everyone aware that there are opportunities to improve care for cardiac patients. The treatments recommended as part of this program have all been proven to work in prospective randomized placebo controlled trials.  The American Heart Association and American College of Cardiology guidelines recommend their use in appropriate patients.  National organizations that assess the quality of health care include the frequency of use of these treatments as quality indicators. It may be easier than you think to have physicians agree when all the evidence supporting treatment is reviewed.  Providing examples of the improved treatment rates that have been accomplished at other medical centers can also help.

Q. Will primary care physicians get upset if patients are started on lipid lowering medications prior to hospital discharge?

A. In the 7 years that CHAMP has been in place at the UCLA Medical Center, there have been no significant complaints.  Having the physicians and nurses that care for patients with cardiovascular disease work together to implement the treatment program can help address any of these concerns. Initiation of lipid lowering treatment prior to hospital discharge can improve patient understanding and compliance with treatment.  Often patients assume that because the physician that treated them during their cardiac hospitalization did not start them on treatment, it is not essential.  Many physicians appreciate that when the first outpatient lipid panel is obtained at 6 weeks after hospital discharge in a patient that was started on lipid lowering therapy, the patient will be much. more likely to be at goal with an LDL < 100 mg/dl.  This approach saves time, minimizes the amount of lab testing required, and helps more patients get to goal quicker. 

Q. Should ACE inhibitors be used for only 6 weeks after myocardial infarction or only in patients with low ejection fraction?

A. While initial studies were done in low ejection fractions or used ACE inhibitors for only 6 weeks after myocardial infarction, new trials clearly demonstrate that all patients with atherosclerosis have reduced risk of myocardial infarction, stroke, cardiac mortality and total mortality with ACE inhibitor treatment.  ACE inhibitors benefit patients with normal or reduced ejection fraction, normal or elevated blood pressure, early or late after myocardial infarction, diabetes or no diabetes.  Thus similar to aspirin, a diagnosis of coronary, cerebral, or peripheral vascular disease, is indication for ACE inhibitor treatment.