Evidence-based practices for patients with cardiac disease.

Mortality rates from coronary heart disease have declined by 25% since 1999, not so much from new designer drugs or improved technology, but through the determined enforcement of basic standards of care that are important enough to be deemed ‘‘guidelines’’ based on ‘‘evidence.’’ Aspirin, patented in 1900, is a medication that is now ubiquitous to the cardiac patient, at least for the last 20 years since we learned it could relieve pain and prevent a heart attack. Statin medications, originally embraced for their cholesterol-lowering effects, also exert substantial benefits through antioxidant, anti-inflammatory, and direct endothelial actions, thus securing their place as a cornerstone of primary and secondary preventive efforts. Both medications are now considered so vital to the prevention of cardiac events, that they have been included in virtually every cardiovascular guideline to date. With over 1000 cardiac-related articles published monthly, the ability to keep pace with new findings while differentiating fact from fancy has become increasingly challenging, even for the most savvy research consumer. Fortunately, the American Heart Association (AHA) has been a leader in disseminating evidence-based cardiovascular practices based on the strength of the literature. Recommendations from the AHA range from Class I (a treatment/procedure that should be used based on current evidence), Class IIa (where it is reasonable to recommend the treatment) or Class IIb (where a treatment may be considered), but additional studies are needed for both, to Class III (where the risks outweigh the benefits and the treatment should not be performed). Class I recommendations that are based on multiple randomized controlled trials or a meta-analysis represent the highest level of evidence, and often proceed along a ‘‘fast-track’’ for dissemination by the AHA. Once such recommendations have been made, it is critically important to then apply the myriad available treatments to a particular patient at a specific point in time. Thus, the concept of evidence-based practice (EBP) comes to fruition. EBP is the integration of the best available evidence with clinical expertise and patient preferences to achieve desired outcomes. It does not necessarily mean implementing research studies to answer a question, but indicates use of a systematic method for using available evidence to guide patient care decisions. For patients with cardiac disease, the AHA and the American College of Cardiology (ACC) offer systematic reviews, Class I guidelines based on the highest level of evidence, to optimize care management. For example, following acute myocardial infarction (AMI), aspirin on arrival, statins and b blocker therapy, smoking cessation advice and a discharge referral to cardiac rehabilitation (new for 2008) are critical performance measures. For the chronic heart failure (CHF) patient, diuretics and salt restriction, angiotensin-converting enzyme (ACE) inhibitors, and b blockers should be standard, as well as educating patients regarding medications, symptom management, and daily weight monitoring. Following coronary artery bypass graft surgery (CABG), aspirin, statins, and b blockers (which prevent perioperative atrial fibrillation) are again advised, as are reduced serum glucose levels and attention to the timing ( 60 minutes before skin incision) and duration (o48 hours) of antibiotic use. The most recently published ACC/AHA guideline addresses, for the first time, the growing population of adults with congenital heart disease, and includes information regarding treatments, exercise, medications, family planning, insurance, referral to specialized centers, and more. In addition to providing the structure of what we should be doing for those with heart disease, the AHA also provides tools that assist in the process of how we can implement these guidelines to achieve the best possible outcomes for cardiac patients. Their Get with the Guidelines program includes a ‘‘toolbox’’ with sample order sets, core measures worksheets, and discharge instructions, as well as tips on overcoming barriers to implementation From the Adult & Pediatric Cardiac Surgery, California Pacific Medical Center, San Francisco, CA Address for correspondence: S. Jill Ley, RN, MS, CNS; 62 Paseo Way, Greenbrae, CA 94904 E-mail: leyj@sutterhealth.org