Women and Heart Disease: The Primary Care Perspective

1. Women and Heart Disease: The Primary Care Perspective Len Fromer, MD Assistant Clinical Professor Department of Family Medicine UCLA School of Medicine Los Angeles, California

2. Leading Cause of Death in Women Heart disease is a leading cause of death in women. According to the American Heart Association, in 2002, 356,000 women in the US died of heart disease. This far exceeds the number of women who have died from stroke, lung cancer, chronic obstructive pulmonary disease and breast cancer. Yet despite the prevalence of heart disease in women, many physicians still regard heat disease as a man�s disorder.Heart disease is a leading cause of death in women. According to the American Heart Association, in 2002, 356,000 women in the US died of heart disease. This far exceeds the number of women who have died from stroke, lung cancer, chronic obstructive pulmonary disease and breast cancer. Yet despite the prevalence of heart disease in women, many physicians still regard heat disease as a man�s disorder.

3. Undertreatment in Women, Despite Increased Prevalence Less cholesterol screening Less use of lipid-lowering therapies Less use of heparin, beta-blockers, and aspirin during myocardial infarction Fewer referrals to cardiac rehabilitation Although the prevalence of heart disease in women is on the rise, heart disease in women remains under-treated. Several recent studies have indicated that versus men women receive less cholesterol screening, less lipid-lowering therapies, less use of heparin, beta-blockers and aspirin during myocardial infarction and fewer referrals to cardiac rehabilitation. References: Chandra NC, et al. Observations of the treatment of women in the United States with myocardial infarction; a report from the National Registry of Myocardial Infarction-I. Arch Intern Med. 1998;158:981-988. Nohria A, et al. Gender differences in coronary artery disease in women: gender differences in mortality after myocardial infarction: why women fare worse than men. Cardiol Clin. 1998;16:45-57. Scott LB, Allen JK. Providers perceptions of factors affecting women�s referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehab. 2004; 24:387-391. O�Meara JG, et al. Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Arch Intern Med. 2004;164:1313-1318. Hendrix KH, et al. Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethn Dis. 2005;15:11-16. Although the prevalence of heart disease in women is on the rise, heart disease in women remains under-treated. Several recent studies have indicated that versus men women receive less cholesterol screening, less lipid-lowering therapies, less use of heparin, beta-blockers and aspirin during myocardial infarction and fewer referrals to cardiac rehabilitation. References: Chandra NC, et al. Observations of the treatment of women in the United States with myocardial infarction; a report from the National Registry of Myocardial Infarction-I. Arch Intern Med. 1998;158:981-988. Nohria A, et al. Gender differences in coronary artery disease in women: gender differences in mortality after myocardial infarction: why women fare worse than men. Cardiol Clin. 1998;16:45-57. Scott LB, Allen JK. Providers perceptions of factors affecting women�s referral to outpatient cardiac rehabilitation programs: an exploratory study. J Cardiopulm Rehab. 2004; 24:387-391. O�Meara JG, et al. Ethnic and sex differences in the prevalence, treatment, and control of dyslipidemia among hypertensive adults in the GENOA study. Arch Intern Med. 2004;164:1313-1318. Hendrix KH, et al. Ethnic, gender, and age-related differences in treatment and control of dyslipidemia in hypertensive patients. Ethn Dis. 2005;15:11-16.

4. Undertreatment in Women: Role of the PCP and OBGyn Increased prevention Screening in the primary care setting Includes OBGyns acting as PCPs Increased treatment Increased referral to cardiologists Primary care practitioners and obstetrician/gynecologists can play important roles in increasing the treatment of heart disease in women. Steps that can be taken include increased patient education and prevention, screening in the primary care setting, increased treatment in primary care and increased referral to cardiologists. Treatment in the primary care setting would benefit from consultation with cardiologists.Primary care practitioners and obstetrician/gynecologists can play important roles in increasing the treatment of heart disease in women. Steps that can be taken include increased patient education and prevention, screening in the primary care setting, increased treatment in primary care and increased referral to cardiologists. Treatment in the primary care setting would benefit from consultation with cardiologists.

5. When to Refer to a Cardiologist Assess risk level based on age, sex, total and LDL cholesterol, smoking, and systolic blood pressure Low Intermediate High Consider referral with intermediate- and high-risk patients Assess the ability of the current primary care practice to meet the patient�s needs Physician comfort level �Tyranny of the urgent� Staff training and facilities Consider consultation as an alternative to referral Develop a standing relationship with a cardiology practice The factors listed above provide a guideline for when to refer to a cardiologist. Patients with CVD risk level may be managed by the PCP with interventions such as diet, exercise counseling and lipid-lowering therapies. Moderate to high risk patients should consider referral to a cardiologist. The decision of the individual PCP will depend on the capabilities of the PCP practice, time constraints and staff training/facilities. Also, consultation with a cardiologist may be an alternative to referral. Describe suggestions for HOW a PCP can best collaborate with a cardiologist. Perhaps setting up a standing relationship with a cardiology practice would be one possibility.The factors listed above provide a guideline for when to refer to a cardiologist. Patients with CVD risk level may be managed by the PCP with interventions such as diet, exercise counseling and lipid-lowering therapies. Moderate to high risk patients should consider referral to a cardiologist. The decision of the individual PCP will depend on the capabilities of the PCP practice, time constraints and staff training/facilities. Also, consultation with a cardiologist may be an alternative to referral. Describe suggestions for HOW a PCP can best collaborate with a cardiologist. Perhaps setting up a standing relationship with a cardiology practice would be one possibility.

6. US 2004 Visits to PCPs by Gender This graph shows the percent of visits to PCPs in the United States in 2004 based on gender. Clearly women utilize PCPs more frequently than men. Of female visits to PCPs, 90.1% were for preventative care. In men the percentage for preventative care was 81.2% Reference: http://www.cdc.gov/nchs/data/ad/ad374.pdfThis graph shows the percent of visits to PCPs in the United States in 2004 based on gender. Clearly women utilize PCPs more frequently than men. Of female visits to PCPs, 90.1% were for preventative care. In men the percentage for preventative care was 81.2% Reference: http://www.cdc.gov/nchs/data/ad/ad374.pdf

7. Encouraging Participatory Patient-Physician Decision Making Understand the patient�s and family members� experience and expectations Build partnership Provide evidence Include a balanced discussion of uncertainties Present recommendations Check for understanding and agreement These are proposed methods of helping patients and their families make use of results of medical research to reach decisions that incorporate evidence and patients� values. The ingredients for effective use of evidence include understanding the patient�s preferred style, informed flexibility in presenting the information to accommodate to the patient�s needs, a visit that is characterized by dialogue rather than lecturing, and an active partnership in which the patient is encouraged and coached to take a more active role in the consultation. Reference: Epstein RM et al. Communicating evidence for participatory decision making. JAMA. 2004;291:2359-66.These are proposed methods of helping patients and their families make use of results of medical research to reach decisions that incorporate evidence and patients� values. The ingredients for effective use of evidence include understanding the patient�s preferred style, informed flexibility in presenting the information to accommodate to the patient�s needs, a visit that is characterized by dialogue rather than lecturing, and an active partnership in which the patient is encouraged and coached to take a more active role in the consultation. Reference: Epstein RM et al. Communicating evidence for participatory decision making. JAMA. 2004;291:2359-66.

8. Women and Health Care Decision-Making Women often play a central role in family health care decisions According to a recent health insurance industry survey: 79% of mothers are responsible for choosing children�s doctors 84% are responsible for taking children to doctor�s appointments 78% are responsible for ensuring children receive recommended care Two-thirds of all women are alone responsible for health care decisions within their family. More than 80 percent have sole or shared responsibility for financial decisions regarding their family's health. Reference: "Majority of Women Control Health Care Decisions", based on a survey conducted by EDK Associates, Merck Media Minutes, Summer 1997.Two-thirds of all women are alone responsible for health care decisions within their family. More than 80 percent have sole or shared responsibility for financial decisions regarding their family's health. Reference: "Majority of Women Control Health Care Decisions", based on a survey conducted by EDK Associates, Merck Media Minutes, Summer 1997.

9. Preventing CHD in Postmenopausal Women OBGyns provide primary health care for many postmenopausal women OBGyns should take a greater role in CHD risk management CHD risk factors in women are well established Risk-factor management must be incorporated into routine primary care practice According to a recent review article published by Welty, because obstetrician-gynecologists provide primary health care for postmenopausal women, it is incumbent upon them to take on a greater role in CHD risk management. CHD risk factors in women are well established, and risk-factor management must be accorded the attention it deserves by incorporating it into routine clinical practice. Reference: Preventing clinically evident coronary heart disease in the postmenopausal woman Welty FK. Menopause. 2004;11:484-494. According to a recent review article published by Welty, because obstetrician-gynecologists provide primary health care for postmenopausal women, it is incumbent upon them to take on a greater role in CHD risk management. CHD risk factors in women are well established, and risk-factor management must be accorded the attention it deserves by incorporating it into routine clinical practice. Reference: Preventing clinically evident coronary heart disease in the postmenopausal woman Welty FK. Menopause. 2004;11:484-494.

10. Promoting Early Diagnosis: The Importance of Screening Screening to determine risk of CVD using a calculator, such as the Framingham based risk calculator, is critical to adequate CVD prevention. The question remains, do PCPs in fact use risk calculators, such as the Framingham NCEP ATP III illustrated here. The Framingham-based risk calculator is a useful tool that can be used by PCPs to measure risk of angina, myocardial infarction, or coronary death within 10 years using a system that includes age, sex, total and LDL cholesterol, smoking, and systolic blood pressure. In addition to the use of these calculators, PCPs need to understand the significance of test results and how they may direct clinical decision-making. Screening to determine risk of CVD using a calculator, such as the Framingham based risk calculator, is critical to adequate CVD prevention. The question remains, do PCPs in fact use risk calculators, such as the Framingham NCEP ATP III illustrated here. The Framingham-based risk calculator is a useful tool that can be used by PCPs to measure risk of angina, myocardial infarction, or coronary death within 10 years using a system that includes age, sex, total and LDL cholesterol, smoking, and systolic blood pressure. In addition to the use of these calculators, PCPs need to understand the significance of test results and how they may direct clinical decision-making.

11. Physician CVD Prevention Guideline Awareness Online study of 500 physicians 300 primary care 100 obstetricians/gynecologists 100 cardiologists Questionnaire assessed awareness and adoption of CVD prevention guidelines by specialty 3 national CVD prevention guidelines used NCEP ATP III JNC 7 AHA Evidence-Based Physician accuracy at assigning CVD risk level assessed A recent study examined the use of risk calculators, including the Framingham-based risk calculator (NCEP ATP III), the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), and the American Heart Association (AHA) evidence-based calculator. This online questionnaire assessed awareness and adoption of CVD prevention guidelines by specialty. Five hundred physicians were included in the study; 300 primary care, 100 obstetricians/gynecologists and 100 cardiologists. Physician accuracy at assigning CVD risk level was assessed. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.A recent study examined the use of risk calculators, including the Framingham-based risk calculator (NCEP ATP III), the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), and the American Heart Association (AHA) evidence-based calculator. This online questionnaire assessed awareness and adoption of CVD prevention guidelines by specialty. Five hundred physicians were included in the study; 300 primary care, 100 obstetricians/gynecologists and 100 cardiologists. Physician accuracy at assigning CVD risk level was assessed. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

12. Physician Awareness of CVD Prevention by Specialty Physician awareness of 3 national CVD prevention guidelines (NCEP ATP III, JNC 7, and AHA Evidence-Based Guidelines for Women) differed by physician specialty and guideline as illustrated in this figure. Among PCPs and CARDs, there was a high level of awareness of NCEP ATP III and JNC 7 guidelines. Awareness of the more recent AHA Evidence-Based Guidelines for Women was lower than NCEP ATP III and JNC 7 and highest among CARDs (80%). OBGyns were more aware of the AHA women�s guidelines than JNC 7 and had similar familiarity with the AHA women�s guidelines and NCEP ATP III. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. Physician awareness of 3 national CVD prevention guidelines (NCEP ATP III, JNC 7, and AHA Evidence-Based Guidelines for Women) differed by physician specialty and guideline as illustrated in this figure. Among PCPs and CARDs, there was a high level of awareness of NCEP ATP III and JNC 7 guidelines. Awareness of the more recent AHA Evidence-Based Guidelines for Women was lower than NCEP ATP III and JNC 7 and highest among CARDs (80%). OBGyns were more aware of the AHA women�s guidelines than JNC 7 and had similar familiarity with the AHA women�s guidelines and NCEP ATP III. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

13. Physician Incorporation of CVD Prevention Guidelines Among Aware Respondents This figure shows self-reported incorporation of guidelines into practice among those who responded that they were aware of specific guidelines. CARDs and PCPs were similar in their reported use of guidelines and were significantly more likely to report incorporation of each of the 3 guidelines into their practice than OBGyns. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. This figure shows self-reported incorporation of guidelines into practice among those who responded that they were aware of specific guidelines. CARDs and PCPs were similar in their reported use of guidelines and were significantly more likely to report incorporation of each of the 3 guidelines into their practice than OBGyns. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

14. Physicians� Recommendations on Lifestyle, Supplement, and Aspirin by Specialty and Patient Risk Level Physician�s recommendations about lifestyle interventions, supplements, and aspirin therapy by physician specialty according to patient risk level are presented in this graph. Of note, recommendations for lifestyle interventions (physical activity and dietary counseling) were suboptimal among low-risk patients across all physician specialties, even though lifestyle strategies to prevent CVD are recommended for all women in the AHA women�s guidelines Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. Physician�s recommendations about lifestyle interventions, supplements, and aspirin therapy by physician specialty according to patient risk level are presented in this graph. Of note, recommendations for lifestyle interventions (physical activity and dietary counseling) were suboptimal among low-risk patients across all physician specialties, even though lifestyle strategies to prevent CVD are recommended for all women in the AHA women�s guidelines Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

15. Identification of Optimal Levels of Lipid/Glycemic Control by Patient Gender and Physician Specialty This graph shows the percent of physicians by specialty that identified various optimal lipid and glucose targets stratified by patient gender. About half of the sample identified optimal LDL levels as 100 mg/dL (2.59 mmol/L) consistent with NCEP ATP III and AHA women�s guidelines. Five percent of OBGyns and 23% of CARDs suggested an LDL level 70 mg/dL (1.81 mmol/L) as an optimal level, in line with the recommendations of the recent update to NCEP ATP III. The data show that physicians recognized gender differences in optimal HDL levels and that 50% of CARDs correctly identified the optimal HDL level of 50 mg/dL (1.30 mmol/L) recommended for women in the AHA guidelines. OBGyns were less likely to correctly identify optimal triglyceride levels (150 mg/dL, 1.70 mmol/L) and an optimal HbA1C level of 7.0% compared with PCPs and CARDs. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. This graph shows the percent of physicians by specialty that identified various optimal lipid and glucose targets stratified by patient gender. About half of the sample identified optimal LDL levels as 100 mg/dL (2.59 mmol/L) consistent with NCEP ATP III and AHA women�s guidelines. Five percent of OBGyns and 23% of CARDs suggested an LDL level 70 mg/dL (1.81 mmol/L) as an optimal level, in line with the recommendations of the recent update to NCEP ATP III. The data show that physicians recognized gender differences in optimal HDL levels and that 50% of CARDs correctly identified the optimal HDL level of 50 mg/dL (1.30 mmol/L) recommended for women in the AHA guidelines. OBGyns were less likely to correctly identify optimal triglyceride levels (150 mg/dL, 1.70 mmol/L) and an optimal HbA1C level of 7.0% compared with PCPs and CARDs. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

16. Correct Categorization of Risk by Specialty Among OBGyns, 19% correctly identified male patient�s risk as low, 41% correctly categorized intermediate-risk patients, and 43% correctly categorized high-risk patients. In their assessment of female patients� risk, OBGyns� accuracy rates were 17%, 38%, and 37%, respectively. CARDs correctly categorized low-risk male patients 29% of the time, 51% correctly categorized intermediate-risk male patients, and 58% correctly identified high-risk male patients. A similar trend was seen for CARDs� evaluation of female patients� risk level (36%, 53%, and 56%, respectively). Data on determinants of physicians assigning increasing risk levels among patients calculated to be at intermediate and high risk as defined by NCEP ATP III reveal a significant influence of patient gender on assignment of risk category. Intermediate-risk women were significantly less likely to be assigned to a higher-risk category than men with similar risk profiles (OR, 0.62; 95% CI, 0.49 to 0.78) by PCPs, with similar but nonsignificant trends for OBGyns and CARDs. For example, PCPs assigned 20% of women compared with 13% of men to the low-risk category with the same risk profile (65 years of age, nonsmoking, LDL cholesterol of 162 mg/dL, HDL cholesterol of 56 mg/dL, BMI of 27 kg/m2, blood pressure of 118/78 mm Hg, positive family history of premature CHD, and no personal history of CVD). Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. Among OBGyns, 19% correctly identified male patient�s risk as low, 41% correctly categorized intermediate-risk patients, and 43% correctly categorized high-risk patients. In their assessment of female patients� risk, OBGyns� accuracy rates were 17%, 38%, and 37%, respectively. CARDs correctly categorized low-risk male patients 29% of the time, 51% correctly categorized intermediate-risk male patients, and 58% correctly identified high-risk male patients. A similar trend was seen for CARDs� evaluation of female patients� risk level (36%, 53%, and 56%, respectively). Data on determinants of physicians assigning increasing risk levels among patients calculated to be at intermediate and high risk as defined by NCEP ATP III reveal a significant influence of patient gender on assignment of risk category. Intermediate-risk women were significantly less likely to be assigned to a higher-risk category than men with similar risk profiles (OR, 0.62; 95% CI, 0.49 to 0.78) by PCPs, with similar but nonsignificant trends for OBGyns and CARDs. For example, PCPs assigned 20% of women compared with 13% of men to the low-risk category with the same risk profile (65 years of age, nonsmoking, LDL cholesterol of 162 mg/dL, HDL cholesterol of 56 mg/dL, BMI of 27 kg/m2, blood pressure of 118/78 mm Hg, positive family history of premature CHD, and no personal history of CVD). Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

17. Physician CVD Prevention Guideline Awareness OBGyns in this study provide primary care to 67% of their patients An opportunity exists for OBGyn education andidentification of CVD in women Cardiologists may be more effective at identifying optimal levels of lipid/glycemic control vs PCPs or OBGyns Collaboration between physician specialties could improve CVD prevention and treatment In general, this study indicated that OBGyns are less aware of national guidelines than PCPs or CARDS. It should be noted that OBGyns in this study provide primary care to 67% of their patients. CARDS may be more effective at identifying optimal levels of lipid/glycemic control vs PCPs or OBGyns. Collaboration between physician specialties could improve CVD prevention and treatment. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510. In general, this study indicated that OBGyns are less aware of national guidelines than PCPs or CARDS. It should be noted that OBGyns in this study provide primary care to 67% of their patients. CARDS may be more effective at identifying optimal levels of lipid/glycemic control vs PCPs or OBGyns. Collaboration between physician specialties could improve CVD prevention and treatment. Reference: Mosca L, Linfante AH, Benjamin EJ, et al. National study of physician awareness and adherence to cardiovascular disease prevention guidelines. Circulation. 2005;111:499-510.

18. Parallel Care vs Serial Care Model Parallel care model (preferred) After a referral for cardiac disease, the PCP continues to care for the entire patient, even the cardiac problem The cardiologist provides crucial input in parallel with the PCP�s overall care Serial care model The patient is cared for by the cardiologist while the cardiac problem is addressed The patient is then sent back to the PCP

19. Heart Disease in Primary Care PCPs may not always be comfortable following AHA/ACC guidelines Practice guidelines do not assure changes in physician behavior, such as data sharing (for example, test reports) Could benefit from communication and collaboration with cardiologists There have been multiple reports of poor physician adherence cardiovascular disease guidelines. Although clinical practice guidelines such as the AHA/ACC guidelines now exist to improve care and patient outcomes, the existence of guidelines does not guarantee changes in physician behavior, such as data sharing between specialities. PCPs may not always be comfortable following AHA/ACC guidelines, and could benefit from communication and collaboration with cardiologists. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9. There have been multiple reports of poor physician adherence cardiovascular disease guidelines. Although clinical practice guidelines such as the AHA/ACC guidelines now exist to improve care and patient outcomes, the existence of guidelines does not guarantee changes in physician behavior, such as data sharing between specialities. PCPs may not always be comfortable following AHA/ACC guidelines, and could benefit from communication and collaboration with cardiologists. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9.

20. Barriers and Interventions Several possible barriers to guideline acceptance and use have been recently described. Barriers include lack of awareness, lack of familiarity with the guidelines, lack of agreement with the guidelines and lack of self-efficacy (ability to use the guidelines). Lack of awareness may be addressed through CME and education, increased guideline distribution, and mass media efforts to increase patient awareness. Lack of familiarity could be remedied by CME programs that focus specifically on teaching physicians about the guidelines. Lack of agreement with the guidelines may be addressed through opinion leader guideline endorsement, physician participation in guideline development, and specialty society endorsement of the guidelines. To address lack of self-efficacy, CME focusing on skills development could be utilized; as well as interactive learning and mechanisms for individual performance feedback. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9. Several possible barriers to guideline acceptance and use have been recently described. Barriers include lack of awareness, lack of familiarity with the guidelines, lack of agreement with the guidelines and lack of self-efficacy (ability to use the guidelines). Lack of awareness may be addressed through CME and education, increased guideline distribution, and mass media efforts to increase patient awareness. Lack of familiarity could be remedied by CME programs that focus specifically on teaching physicians about the guidelines. Lack of agreement with the guidelines may be addressed through opinion leader guideline endorsement, physician participation in guideline development, and specialty society endorsement of the guidelines. To address lack of self-efficacy, CME focusing on skills development could be utilized; as well as interactive learning and mechanisms for individual performance feedback. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9.

21. Barriers and Interventions Additional barriers include lack of outcome expectancy (inability to predict or understand the outcome of using guidelines), the inertia of previous practice (habit), and external barriers such as financial or staff limitations. Lack of outcome expectancy may be addressed by audit and feedback of practice-wide performance and the citation of previous published success at improving outcomes through guideline implementation as examples. Inertia of previous practice may be addressed by motivational strategies that utilize audit and feedback and by the influence of opinion leaders. External barriers may be addressed by addressing the specific barrier, for example the lack of a reminder system, poor staff support to implement guidelines or poor reimbursement. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9. Additional barriers include lack of outcome expectancy (inability to predict or understand the outcome of using guidelines), the inertia of previous practice (habit), and external barriers such as financial or staff limitations. Lack of outcome expectancy may be addressed by audit and feedback of practice-wide performance and the citation of previous published success at improving outcomes through guideline implementation as examples. Inertia of previous practice may be addressed by motivational strategies that utilize audit and feedback and by the influence of opinion leaders. External barriers may be addressed by addressing the specific barrier, for example the lack of a reminder system, poor staff support to implement guidelines or poor reimbursement. Reference: Cabana MD, Kim C. Physician adherence to preventive cardiology guidelines for women. Womens Health Issues. 2003 Jul-Aug;13(4):142-9.

22. Heart Failure in Primary Care Heart failure is prevalent in women and generally treated in primary care. A recent UK survey (conducted in 15 countries) assessed how PCPs believe heart failure should be managed 1363 physicians provided data for 11,062 patients Heart failure is a prevalent problem in women and is generally treated in primary care. A recent UK survey (conducted in 15 countries) assessed how PCPs believe heart failure should be managed. In this study, 1363 physicians provided data for 11,062 patients. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9. Heart failure is a prevalent problem in women and is generally treated in primary care. A recent UK survey (conducted in 15 countries) assessed how PCPs believe heart failure should be managed. In this study, 1363 physicians provided data for 11,062 patients. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9.

23. Primary Care Perceptions of Drug Effectiveness and Treatment Aims The figure on the left shows responses of primary care physicians to the statement �In patients with heart failure and left ventricular systolic dysfunction, the following treatments have definitely been shown to improve symptoms and/or prognosis.� Physicians were aware of ACE inhibitor benefits, but less aware of beta-blockers. The figure on the right shows the rank order of therapeutic aims in practice for patients aged above and below age 70. Overall, slowing progression of disease was the main therapeutic aim. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9. The figure on the left shows responses of primary care physicians to the statement �In patients with heart failure and left ventricular systolic dysfunction, the following treatments have definitely been shown to improve symptoms and/or prognosis.� Physicians were aware of ACE inhibitor benefits, but less aware of beta-blockers. The figure on the right shows the rank order of therapeutic aims in practice for patients aged above and below age 70. Overall, slowing progression of disease was the main therapeutic aim. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9.

24. Percentage of Patients Receiving an ACE Inhibitor at or Above Target Dose In practice, overall doses of ACE inhibitors prescribed were about 50% of the target doses suggested in European guidelines. Compared with other ACE inhibitors, captopril was least likely and perindopril was mostly likely to be prescribed at target doses. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9. In practice, overall doses of ACE inhibitors prescribed were about 50% of the target doses suggested in European guidelines. Compared with other ACE inhibitors, captopril was least likely and perindopril was mostly likely to be prescribed at target doses. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9.

25. Physicians well informed about ACE inhibitor benefits, lesser awareness of beta-blockers Up to 90% of patients diagnosed with heart failure receive correct investigations Possibly due to high hospital admission rate in this study Actual treatment suboptimal 60% of patients received ACE inhibitor Only 20% received ACE with beta-blocker Heart failure knowledge and resources adequate, actual care lagging Better care coordination needed, such as consultation with cardiologists Heart Failure in Primary Care This study demonstrated that in primary care, physicians were well-informed about ACE inhibitor benefits, lesser awareness of beta-blockers. Up to 90% of patients diagnosed with heart failure receive correct investigations, although this was possibly due to high hospital admission rate in this study. Actual treatment was suboptimal in that only 60% of patients received ACE inhibitor and only 20% received an ACE inhibitor with a beta-blocker. It appears that in the European primary care setting heart failure knowledge and resources were adequate, but actual care was lagging. A similar study conducted in the United States would be of interest, although Western European practices may be expected to be fairly representative of primary care practices in the United Statses. Better care coordination is needed, such as consultation of primary care physicians with cardiologists. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9. This study demonstrated that in primary care, physicians were well-informed about ACE inhibitor benefits, lesser awareness of beta-blockers. Up to 90% of patients diagnosed with heart failure receive correct investigations, although this was possibly due to high hospital admission rate in this study. Actual treatment was suboptimal in that only 60% of patients received ACE inhibitor and only 20% received an ACE inhibitor with a beta-blocker. It appears that in the European primary care setting heart failure knowledge and resources were adequate, but actual care was lagging. A similar study conducted in the United States would be of interest, although Western European practices may be expected to be fairly representative of primary care practices in the United Statses. Better care coordination is needed, such as consultation of primary care physicians with cardiologists. Reference: Cleland JG, Cohen-Solal A, Aguilar JC, et al; IMPROVEMENT of Heart Failure Programme Committees and Investigators. Improvement programme in evaluation and management; Study Group on Diagnosis of the Working Group on Heart Failure of The European Society of Cardiology. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet. 2002 Nov 23;360(9346):1631-9.

26. Specialist Intervention Influence on PCP Care of MI and Heart Failure 509 patients with MI, 323 patients with heart failure Two PCP groups assessed: with or without guideline compliance PCP records reviewed over 6 months to assess guideline compliance Seven measures of MI care Eight measures of heart failure care Subgroup of PCPs who followed practice guidelines assessed with or without cardiologist collaboration The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from the hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure. A subgroup of PCPs who followed practice guidelines was assessed with or without cardiologist collaboration. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9. The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from the hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure. A subgroup of PCPs who followed practice guidelines was assessed with or without cardiologist collaboration. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9.

27. Cardiologist Influence on PCP Care of MI The conformance score for patients with myocardial infarction who were seen by both a primary care provider and a cardiologist was higher than the score for patients seen by a primary care provider only (P<0.0001). Individual performance measures for beta blockers, aspirin, and appropriate cholesterol testing were high (90%) for care delivered by either primary care providers alone or primary care providers and cardiologists. However, more patients cared for by cardiologists were prescribed an angiotensin converting enzyme inhibitor as compared with patients cared for by primary care physicians only (P <0.0001), and patients seen by cardiologists more often underwent testing to determine left ventricular ejection fraction (P< 0.001). Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9.The conformance score for patients with myocardial infarction who were seen by both a primary care provider and a cardiologist was higher than the score for patients seen by a primary care provider only (P<0.0001). Individual performance measures for beta blockers, aspirin, and appropriate cholesterol testing were high (90%) for care delivered by either primary care providers alone or primary care providers and cardiologists. However, more patients cared for by cardiologists were prescribed an angiotensin converting enzyme inhibitor as compared with patients cared for by primary care physicians only (P <0.0001), and patients seen by cardiologists more often underwent testing to determine left ventricular ejection fraction (P< 0.001). Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9.

28. Cardiologist Influence on PCP Care of Heart Failure The unadjusted conformance score for patients with heart failure who were seen by a cardiologist was greater than that for patients seen by a primary care physician only (P< 0.0001). With respect to individual performance measures, those cared for by cardiologists were more likely to undergo testing to determine left ventricular ejection fraction (P 0.01), have their weight assessed (P 0.0004), have an assessment for peripheral edema (P0.01), or be given advice on salt restriction (P <0.01), compared with those cared for by a primary care physician only. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9. The unadjusted conformance score for patients with heart failure who were seen by a cardiologist was greater than that for patients seen by a primary care physician only (P< 0.0001). With respect to individual performance measures, those cared for by cardiologists were more likely to undergo testing to determine left ventricular ejection fraction (P 0.01), have their weight assessed (P 0.0004), have an assessment for peripheral edema (P0.01), or be given advice on salt restriction (P <0.01), compared with those cared for by a primary care physician only. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9.

29. Cardiologist Influence on PCP Care of Heart Failure Treatment better for patients seen by both PCPs and cardiologists Approximately half of patients with MI and 40% of those with heart failure saw a cardiologist after hospital discharge Care for patients with MI or heart failure is improved when a cardiologist is involved Overall treatment was better for patients seen by both PCPs and cardiologists. Approximately half of patients with MI and 40% of those with heart failure saw a cardiologist after hospital discharge. Primary care for patients with MI or heart failure improves when a cardiologist is involved. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9. Overall treatment was better for patients seen by both PCPs and cardiologists. Approximately half of patients with MI and 40% of those with heart failure saw a cardiologist after hospital discharge. Primary care for patients with MI or heart failure improves when a cardiologist is involved. Reference: Guadagnoli E, Normand SL, DiSalvo TG, Palmer RH, McNeil BJ. Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure. Am J Med. 2004;117:371-9.

30. Heart Failure in Primary Care Heart failure (HF) disease management program (DMP), 4 patients w/advanced HF and low ejection fractions almost fully recovered at 4-45 months With later PCP treatment, symptom relapse and left ventricular function deterioration occurred in all Readmission to the HF DMP reinstated improvement In a heart failure (HF) disease management program (DMP), 4 patients with advanced HF and low ejection fractions had near full recovery within 4 to 45 months. When discharged to their primary care physicians, all 4 had severe symptom relapse and deterioration of their left ventricular function. Readmission to the HF DMP for a second time resulted in similar improvement in all parameters, as was seen the first time. Reference: Saucier N., et al. Comparison of Management of Four Patients With Idiopathic Dilated Cardiomyopathy in a Disease Management Program Versus by a Primary Care Physician.� Am J Cardiol. 2006;9:253-255. In a heart failure (HF) disease management program (DMP), 4 patients with advanced HF and low ejection fractions had near full recovery within 4 to 45 months. When discharged to their primary care physicians, all 4 had severe symptom relapse and deterioration of their left ventricular function. Readmission to the HF DMP for a second time resulted in similar improvement in all parameters, as was seen the first time. Reference: Saucier N., et al. Comparison of Management of Four Patients With Idiopathic Dilated Cardiomyopathy in a Disease Management Program Versus by a Primary Care Physician.� Am J Cardiol. 2006;9:253-255.

31. Heart Failure in Primary Care 113 patients with confirmed left ventricular systolic dysfunction randomized to specialist or primary care ACE inhibitors (85% vs 64%) and beta-blockers (50% vs 2%) higher in specialist care patients Patients with suspected heart failure referred for open access echocardiography to a hospital-based echocardiography service were assessed from June 2002 through to June 2003. Patients with confirmed left ventricular systolic dysfunction (LVSD) were randomized to specialist care (cardiology registrar and heart failure nurses) or referred back to their general practitioner. 386 patients were screened; mean age -72+/-10 years. 113 (29%) had confirmed LVSD on echocardiography and were randomized to specialist or primary care. The prescription of ACE-inhibitors (85% vs. 64%) and beta blockers (50% vs. 2%) was higher in patients randomized to specialist care. No significant differences were noted in mortality or hospitalization. Reference: Rao A, Walsh J. Impact of specialist care in patients with newly diagnosed heart failure: A randomised controlled study. Int J Cardiol. 2006 Jun 28; [Epub ahead of print] Patients with suspected heart failure referred for open access echocardiography to a hospital-based echocardiography service were assessed from June 2002 through to June 2003. Patients with confirmed left ventricular systolic dysfunction (LVSD) were randomized to specialist care (cardiology registrar and heart failure nurses) or referred back to their general practitioner. 386 patients were screened; mean age -72+/-10 years. 113 (29%) had confirmed LVSD on echocardiography and were randomized to specialist or primary care. The prescription of ACE-inhibitors (85% vs. 64%) and beta blockers (50% vs. 2%) was higher in patients randomized to specialist care. No significant differences were noted in mortality or hospitalization. Reference: Rao A, Walsh J. Impact of specialist care in patients with newly diagnosed heart failure: A randomised controlled study. Int J Cardiol. 2006 Jun 28; [Epub ahead of print]

32. Roads to Collaboration Prevention, screening, and care is improved by PCP/specialist collaboration Local opinion leader advocacy can help change physician practice and encourage collaboration1 Prevention, screening and care is improved by PCP/specialist collaboration. Local opinion leader advocacy can help change physician practice and encourage collaboration.1 CME or educational programs (such as this one) combining the efforts of cardiologists and PCPs can help, particularly if a mixed cardio/PCP audience attends. Review articles emphasizing collaboration with cardiologists published in PCP journals may encourage collaboration. Awareness of heart disease in women needs to be improved in all physician specialties. 1. Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. QRB Qual Rev Bull. 1992;18:413-22. Prevention, screening and care is improved by PCP/specialist collaboration. Local opinion leader advocacy can help change physician practice and encourage collaboration.1 CME or educational programs (such as this one) combining the efforts of cardiologists and PCPs can help, particularly if a mixed cardio/PCP audience attends. Review articles emphasizing collaboration with cardiologists published in PCP journals may encourage collaboration. Awareness of heart disease in women needs to be improved in all physician specialties. 1. Mittman BS, Tonesk X, Jacobson PD. Implementing clinical practice guidelines: social influence strategies and practitioner behavior change. QRB Qual Rev Bull. 1992;18:413-22.

33. Roads to Collaboration CME or educational programs (such as this one) combining the efforts of cardiologists and PCPs can help, particularly if a mixed cardio/PCP audience attends Review articles emphasizing collaboration with cardiologists published in PCP journals may encourage collaboration Awareness of heart disease in women needs to be improved in all physician specialties