2011 Guidelines for Secondary Prevention of CVD: Evidence-based Tools

The 2011 update of the guidelines for secondary prevention and risk reduction therapy for patients with established cardiovascular disease is the culmination of five years of additional efforts since a similar document was published in 2006¹ to establish the “merits of intensive risk-reduction therapies” to improve outcomes and enhance quality of life.² The writing committee has reviewed numerous related cardiovascular guidelines and prevention studies to develop these evidence-based recommendations, which cover smoking cessation, blood pressure and lipid control, physical activity, weight and depression management, and specific pharmacologic therapies. Undoubtedly, countless hours were devoted to the careful construction of the recommendations, in the hope that the significant morbidity and mortality from cardiovascular complications currently documented can be partially assuaged.³

It is interesting to reflect on some of the common language used to craft the recommendations, as a guide to the next steps for implementation of this publication. First, the guidelines are patient focused, proposing clinicians to ask, counsel, and encourage the individuals in their examining rooms. This necessitates a conversation about lifestyle, and mood, along with the routine questions about angina or claudication. Note, too, that the recommendations require the clinician to have discrete data documented in the chart, as part of the goal setting for the individual patient. Ongoing data that needs to be collected and actively utilized include body mass index (BMI), waist circumference, left ventricular ejection fraction, LDL cholesterol, hemoglobin A1C, and influenza vaccination. Finally, the appropriate institution of pharmacotherapies demands an up-to-date list of medical problems for each patient, including past coronary surgery or stent, diabetes, renal function, and results of carotid screening. Two important concepts are also highlighted in the current guidelines: the aging of our population with a resultant increase in cardiovascular disease, and the evidence that life-saving therapies are under-utilized. Clearly, the challenge now is to develop systems of care that incorporate discrete patient data and problem lists with concurrent therapy in the context of guideline-based management, all without sacrificing the important therapeutic conversation between a patient and clinician.

As with any other complex problem involving many variables, computer based systems may be a solution.⁴ There has been a major focus on the use of electronic medical records (EMR) to facilitate optimal care for other disease states, and the technology is ideally suited for the secondary prevention of atherosclerotic vascular disease as well.^5-6 Increasingly, cardiology and general medicine practices are leveraging the power of the EMR to provide clinical decision support. Automated reminder systems, guidelines and algorithms for stepped care are easy to configure in most EMRs, but are only as good as the discrete data and problem lists that are documented. All of which circles back to the role of the clinician: to ask, counsel and encourage their patients about lifestyle and medications, prompted by an EMR, and empowered by the evidence of our newest guidelines.