Comanagement of Risk Factors in Patients With Coronary Artery Disease: Insights From the APPEAR Study

• Published in: Journal of the American Heart Association Vol. 9; no. 11; p. e015157
• Main Authors: Hejjaji, Vittal, Gosch, Kensey, Jones, Philip G, Breeding, Tracie, Spertus, John A, Arnold, Suzanne V
• Format: Journal Article
• Language: English
• Published: England John Wiley and Sons Inc 02-06-2020; Wiley
• Subjects: Aged; Aged, 80 and over; Antihypertensive Agents - adverse effects; Antihypertensive Agents - therapeutic use; Brief Communication; Cardiologists; comanagement; Coronary Artery Bypass; Coronary Artery Disease - diagnosis; Coronary Artery Disease - epidemiology; Coronary Artery Disease - prevention & control; Cross-Sectional Studies; Delivery of Health Care, Integrated; Dyslipidemias - diagnosis; Dyslipidemias - drug therapy; Dyslipidemias - epidemiology; Female; Heart Disease Risk Factors; Humans; Hydroxymethylglutaryl-CoA Reductase Inhibitors - adverse effects; Hydroxymethylglutaryl-CoA Reductase Inhibitors - therapeutic use; Hypertension - diagnosis; Hypertension - drug therapy; Hypertension - epidemiology; Male; Middle Aged; Patient Care Team; Percutaneous Coronary Intervention; Physicians, Primary Care; Prevalence; Risk Assessment; risk factors; Secondary Prevention; Time Factors; Treatment Outcome; United States - epidemiology; United States; comanagement; risk factors; secondary prevention
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.119.015157

Background Effective management of cardiovascular risk factors is the foundation of secondary prevention in coronary artery disease. The physician under whose sphere these are managed can vary, primary care physicians, cardiologists, or both, and the optimal management strategy for risk factor control is unknown. Methods and Results The APPEAR (Angina Prevalence and Provider Evaluation of Angina Relief) study was a cross-sectional cohort study of outpatients with coronary artery disease (stable angina, percutaneous coronary intervention, coronary artery bypass grafting, or myocardial infarction) from 25 US cardiology practices. After each patient visit, providers noted who managed each risk factor. Blood pressure and lipid levels were recorded from charts. We compared adherence to guideline-directed risk factor control between management strategies (primary care physician alone, cardiologist alone, or comanaged). Among 1259 outpatients with coronary artery disease (mean [SD] age, 71 [11.1] years; 69% men), blood pressure and lipid management strategy varied. Mean blood pressure was 127.9/72.3 mm Hg, with 74% of patients at <140/90 mm Hg and 46% at <130/80 mm Hg. Mean low-density lipoprotein was 83.5 mg/dL, with 75% of patients at <100 mg/dL and 91% on appropriate statin therapy. Patients managed by cardiologists alone tended to have higher rates of risk factor control for both blood pressure and lipids, even after adjusting for covariates. Conclusions Although comanagement has shown benefit in some clinical situations, we found that risk factor control in patients with coronary artery disease tended to be poorer when care was shared between cardiologists and primary care physicians. Further research is needed to better define which conditions are best comanaged and how to more effectively comanage patients in the fractured US healthcare system.