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In-hospital Initiation of Cardiovascular Protective Therapies to Improve Treatment Rates and Clinical OutcomesThe University of California—Los Angeles, Cardiovascular Hospitalization Atherosclerosis Management Program |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 61-70
Gregg Fonarow,
Anna Gawlinski,
Karol Watson,
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摘要:
Despite the scientific evidence that secondary prevention medical therapies reduce mortality in patients with established atherosclerosis, these therapies continue to be underused in patients receiving conventional care. To address this issue, the University of California, Los Angeles, Cardiovascular Hospitalization Atherosclerosis Management Program was implemented in 1994. This hospital-based system focused on initiation of antiplatelet therapy, beta-blocker, angiotensin-converting enzyme inhibitor, and statin therapy (irrespective of baseline low-density lipoprotein cholesterol) in conjunction with diet and exercise counseling in patients hospitalized with coronary artery and other atherosclerotic vascular disease. Preprinted orders, critical pathways, discharge forms, physician and nursing education, pocket cards, patient educational material, and treatment utilization reports facilitated program implementation. Statin use at the time of discharge increased from 6% before initiation of the program to 86% after the Cardiovascular Hospitalization Atherosclerosis Management Program was implemented (P< 0.001). Improved use of aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors was also observed. Importantly, in-hospital initiation of cardiovascular protective therapies had a dramatic effect on long-term treatment rates and patient compliance. The improved use of cardiovascular protective therapies was associated with a significant reduction in clinical events the first year after discharge: the death and nonfatal myocardial infarction rate decreased from 14.8% to 6.4% (odds ratio, 0.43; 95% confidence interval, 0.27–0.59;P< 0.01). These improved treatment rates have been sustained over an 8-year period. Compared with conventional care, the Cardiovascular Hospitalization Atherosclerosis Management Program has been associated with a significant increase in treatment utilization of evidence-based medications, more patients achieving low-density lipoprotein cholesterol less than 100 mg/dL, and improved clinical outcomes in patients hospitalized for cardiovascular disease. Hospital-based atherosclerosis treatment systems are an important step to help eliminate the cardiovascular treatment gap and dramatically reduce the death and disability caused by atherosclerotic vascular disease.
ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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Acute Coronary Syndrome Emergency Treatment StrategiesA Rationale and Road Map for Critical Pathway Implementation |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 71-87
John Corbelli,
David Janicke,
Jennifer Corbelli,
Sheryl Chow,
Mary Pruski,
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摘要:
Clinical guidelines have been established to improve the effectiveness of treatment of patients seeking treatment for acute coronary syndromes and to address the variability in physician approaches to these risks. In patients with established coronary heart disease, clinical trials have consistently demonstrated reduction in morbidity and mortality with secondary prevention therapies. Both ends of this spectrum of therapy can be underused in patients receiving conventional care. Because implementation of evidence-based guideline recommendations into clinical care is limited, presented here is a rationale and process that have been successful in guideline implementation for patients with acute coronary syndromes.
ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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Critical Pathway for an Aggressive Diagnostic Strategy for Patients Who Present With Chest Pain but a Nondiagnostic Electrocardiogram to the Emergency Department |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 88-94
Stephen Stowers,
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摘要:
BackgroundThe prolonged length of stay for patients who seek treatment in the emergency department with chest pain and normal or nondiagnostic electrocardiogram has led to a backlog of patients in the emergency department and the telemetry unit. Correct early management requires risk stratification processes that can effectively separate the majority of these patients into low-risk, low/intermediate-risk, intermediate-risk, and high-risk subsets.Methods and ResultsPatients who seek treatment in the emergency department with chest pain are risk-stratified into low-risk, low/intermediate-risk, and high-risk categories using a Risk Score to determine who would benefit from immediate exercise stress testing. Nurse-directed exercise stress testing using the Duke Treadmill Score is used to risk-stratify intermediate-risk patients further “on-the-fly”. Intermediate-risk Duke Treadmill Score patients are injected during exercise with a99mTc-myocardial perfusion agent and undergo a gated single-photon emission computed tomography study. Normal exercise and single-photon emission computed tomography perfusion patients are discharged home. The overall length of stay and 30-day outcomes of these facilitated patients were compared with those of patients treated with a conservative approach using sequential electrocardiograms and cardiac enzymes. Patients who were evaluated using the facilitated approach had a shorter mean length of stay than those using a conservative method, with similar outcomes at 30 days.ConclusionsA facilitated approach incorporating on-demand nurse-directed early exercise stress testing with the injection of a99mTc-myocardial perfusion agent on the fly in intermediate-risk patients is safe and has decreased the backlog of patients in the emergency department and telemetry unit and expedited appropriate treatment of patients with acute chest pain and nondiagnostic electrocardiograms.
ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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4. |
Comment on “Critical Pathway for an Aggressive Diagnostic Strategy for Patients Who Present with Chest Pain, but Non-Diagnostic EKG to the Emergency Department” |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 95-95
Raymond Bahr,
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ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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Periprocedural Management of the Chronically Anticoagulated PatientCritical Pathways for Bridging Therapy |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 96-103
Gregory Piazza,
Samuel Goldhaber,
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摘要:
Periprocedural bridging of the patient on long-term anticoagulation is indicated in nonvalvular atrial fibrillation with additional risk factors, prosthetic heart valves, venous thromboembolism within 3 months of the procedure, and hypercoagulable conditions requiring oral anticoagulation. Until recently, intravenous unfractionated heparin was used for bridging. LMWH has now emerged as a safe and effective bridging alternative.
ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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6. |
Value of the History in Evaluating Patients for Early Myocardial Ischemia in Observation Chest Pain Centers |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 104-112
Raymond Bahr,
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PDF (740KB)
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ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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7. |
Design of a Comprehensive Chest Pain Initiative in an Academic Urban Hospital |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 113-117
Angelo Biviano,
Steven Bergmann,
Joseph Tenenbaum,
Jennifer Sullivan,
Eileen Hurley,
James Giglio,
LeRoy Rabbani,
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摘要:
We describe the development and institution of an initiative based on a clinical diagnostic algorithm and treatment pathways, facilitated by cardiac nurse practitioners, for the treatment of the diverse group of patients with chest pain who seek treatment at our urban-based institution. We believe that our chest pain initiative incorporates previous strategies of rapid emergency department management with inpatient-based care while providing a framework for outpatient follow-up and secondary prevention. These strategies allow our hospital to meet its goals of providing chest pain patients with standardized, high-quality, and expeditious care, given the challenges faced by an academic urban hospital.
ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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8. |
Early Warning Signs of Heart AttackThree Decades of Public and Professional Education in the Southwest Missouri Ozarks |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 118-124
Glenn Turner,
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PDF (655KB)
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ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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9. |
Complicated Myocardial Infarction |
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Critical Pathways in Cardiology: A Journal of Evidence-Based Medicine,
Volume 2,
Issue 2,
2003,
Page 125-152
Richard Becker,
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PDF (1440KB)
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ISSN:1535-282X
出版商:OVID
年代:2003
数据来源: OVID
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