Title: Rationale and Design of the Cardiac Hospitalization Atherosclerosis Management Program (CHAMP) at the University of California Los Angeles
1Rationale and Design of the Cardiac
Hospitalization Atherosclerosis Management
Program (CHAMP) at the University of California
Los Angeles
- Gregg C. Fonarow, MD and Anna Gawlinski, DNSc
Am J Cardiol 20008510A-17A
2CHAMP Background
- Consistent and compelling clinical trial evidence
has demonstrated that risk-factor modification
and treatment can markedly decrease the risk of
future coronary events and prolong survival in
patients with documented CAD. - Despite this clear and consistent evidence,
secondary-prevention medical therapies are
underutilized in patients receiving conventional
care. - To address this issue, a Cardiac Hospitalization
Atherosclerosis Management Program (CHAMP), was
established and implemented at UCLA Medical
Center starting in 1994.
Am J Cardiol 20008510A-17A
3CHAMP Program Overview (1)
- The Cardiac Hospitalization Atherosclerosis
Management Program (CHAMP) focused on initiation
of - aspirin
- cholesterol-lowering therapy (statins) titrated
to achieve an LDL-C of lt 100 mg/dL - beta-blocker
- ACEI
- This was done in conjunction with diet, exercise
and smoking cessation counseling before hospital
discharge in patients with established coronary
artery disease
Am J Cardiol 20008510A-17A
4CHAMP Program Overview (2)
- Implementation of CHAMP involved the use of
- a focused treatment guideline
- standardized admission orders
- educational lectures by local thought leaders
- tracking/reporting of treatment rates
- To assess the impact of the program, treatment
rates and clinical outcomes were compared in
patients discharged in the 2-year period before
and after CHAMP was implemented.
Am J Cardiol 20008510A-17A
5CHAMP Medical Regimen for Patients with
Atherosclerosis (1)
- Aspirin
- Patients should continue on 81-325 mg aspirin/day
indefinitely after discharge. - Cholesterol-Lowering Medications
- Patients with CAD should be started on an HMG-CoA
reductase inhibitor to lower cholesterol and
treat the underlying atherosclerosis disease
process. Starting dose should be the dose
estimated to achieve and LDL lt 100 mg/dL based on
the lipid panel. - Beta Blockers
- These agents should be considered in all patients
with CAD, because they reduce the risk of MI and
make it more likely that a patient will survive
an infarction. Use target doses as clinically
tolerated.
Am J Cardiol 20008510A-17A
6CHAMP Medical Regimen for Patients with
Atherosclerosis (2)
- ACE Inhibitors
- These agents have potent vascular and cardiac
protective effects. These agents are potentially
indicated in all patients with atherosclerosis.
All patients with myocardial infarction without
contraindications should be started on ACEIs
within 24 hours and treated long term. Use
target doses. - Nitrates
- These agents should be considered second-line
agents after b-blockers for the symptomatic
control or angina. There is no long term data
showing that nitrates improve prognosis in
patients with CAD, so their use is simply for
symptom relief.
Am J Cardiol 20008510A-17A
7CHAMP Medical Regimen for Patients with
Atherosclerosis (3)
- Calcium Antagonists
- These agents decrease chest pain but do not
decrease the risk of a cardiac event or improve
survival. They should, in general, not be
prescribed to patients with known CAD. - Antiarrhythmic Agents
- Type I antiarrhythmic agents increase the risk of
sudden death in patients with CAD. These agents
should be avoided in all patients with CAD except
those with implantable cardioverter
defibrillators or in whom the risk/benefit ratio
has been carefully considered. Amiodarone should
be considered the only safe antiarrhythmic agent
in patients with CAD.
Am J Cardiol 20008510A-17A
8CHAMP Medical Regimen for Patients with
Atherosclerosis (4)
- Exercise
- Patients should receive specific instructions for
a daily aerobic exercise program. Either a
home-based program or a supervised cardiac
rehabilitation can be recommended. This is an
essential component of the management of patients
with CAD and is highly effective in preventing
subsequent cardiac events. - Smoking Cessation
- Particular attention should be paid to smoking
cessation as patients who continue to smoke after
presenting with unstable angina have 5.4 times
the risk of death from all causes compared with
patients who stop smoking. Patients should be
offered intensive smoking cessation during
hospitalization. This should include both
physician and nurse counseling focusing on
relapse prevention.
Am J Cardiol 20008510A-17A
9CHAMP Medical Regimen for Patients with
Atherosclerosis (5)
- Diet
- Studies with statins that have demonstrated
reduction in mortality, have utilized these
medications in conjunction with dietary
counseling. Patients and family members, if
available, should receive counseling on the NCEP
Step 2 Diet during the hospitalization.
Information on the outpatient dietary
modification programs available should also be
provided. - Patient Education
- The patient and his or her family member or
advocate should be instructed on the use of
medications and monitoring of symptoms. The
purpose, dose, and major side effects of each
medication prescribed should be explained.
Written medication sheets and a medication
schedule should be provided along with
instructions on what to do if either persistent
side effects or recurrent symptoms occur.
Am J Cardiol 20008510A-17A
10CHAMP Medical Regimen for Patients with
Atherosclerosis (6)
- Follow-up
- Continuation of the therapies targeting the
underlying atherosclerosis disease process
markedly improves clinical outcome in patients
with atherosclerosis. - The continued beneficial therapies prescribed
should be strongly reinforced during patient
follow-up. - A fasting lipid panel should be obtained at 6
weeks to evaluate whether target lipid levels
have been achieved and to guide
cholesterol-lowering medication dosing
adjustments.
Am J Cardiol 20008510A-17A
11CHAMP Algorithm for Patients with Clinically
Evident Atherosclerosis
Clinical Ultrasound Stress Test Angiographic
Coronary Carotid Peripheral
Atherosclerosis
Admission Lipid Panel, LFTs
Aspirin, Beta Blocker, ACEI, HMG CoA Reductase
Inhibitor Exercise and Dietary Counseling
Inpatient Hospitalization Initial Outpatient
Encounter
LDL gt 100 mg/dL
LDL lt 100 mg/dL
Advance Dose and/or Add Niacin, Resin Recheck in
6 weeks
Continue Treatment Recheck in 3-6 months
Am J Cardiol 20008510A-17A
12CHAMP Safety of Initiating Statins During
Hospitalization
Primary Diagnosis n Admit
Discharge Abnormal Rehosp Statin Rx,
Statin, Rx, LFT due to Rx Unstable
angina 224 14 82 1
0 Acute MI 302 8 86 0
0 Chest pain 326 15 74 0
0 PTCA 340 8 92
0 0 Heart failure 371 22
76 2 0 CABG 216 16
68 0 0 Total 1,779 14
80 3/1,423 0/1,423
LFT liver function tests gt 3 times control
requiring discontinuation of therapy
Am J Cardiol 20008510A-17A
13CHAMP Medication Utilization Rates at Discharge
Pre-CHAMP Post-CHAMP (1992-1993) (1994-1
995) Discharge Therapy (n256), (n302),
p value Aspirin 78
92 lt0.001 b-blocker 12
61 lt0.001 Nitrate 62
34 Calcium antagonists 68
12 ACE inhibitors 4
56 lt0.001 HMG-CoA RI 6
86 lt0.0001
Am J Cardiol 20008510A-17A
14CHAMP Medication Utilization Rates and LDL
Levels at One Year Post Hospital Discharge
Pre-CHAMP Post-CHAMP (1992-1993) (1994-1
995) p value
Cholesterol-lowering medication 10
91 lt0.0001 LDL lt 100 mg/dL 6
58 lt0.0001
The impact of this increased treatment
utilization on clinical outcomes is currently
being analyzed
Am J Cardiol 20008510A-17A
15CHAMP Summary
- The initial observations with CHAMP have
demonstrated that CAD risk-factor modification
and treatment can be systematically integrated
into the treatment provided during cardiac
hospitalization utilizing existing resources and
medical personnel and that they appear to be
considerably more effective than conventional
guidelines and care. - The inpatient setting can provide an important
opportunity to initiate secondary-prevention
medical therapies in patients hospitalized with
CAD, presumably impacting the risk of future
coronary events and prolonging life in the large
number of CAD patients hospitalized each year.
Am J Cardiol 20008510A-17A