Clinical Performance Measures for Cardiovascular Disease
The American College of Cardiology, the American Heart Association, and the Physician Consortium for Performance Improvement have developed clinical performance measures for treating patients with coronary artery disease (CAD) and heart failure. The standards are available online at http://www.acc.org/clinical/measures/intro.htm.
Coronary Artery Disease. The CAD guidelines include monitoring of blood pressure and lipid levels, assessment of symptoms and activity, and counseling for smoking cessation, if necessary. A blood pressure reading should be taken at every office visit. Target blood pressure in patients with coexisting conditions (e.g., diabetes, heart failure, renal failure) is 130/85 mm Hg. In patients with no coexisting conditions, the target is less than 140/90 mm Hg.
Antiplatelet therapy is recommended for patients with CAD. Aspirin should be prescribed for patients with no contraindications. If contraindications exist, other agents such as clopidogrel (Plavix) may be substituted. Low-density lipoprotein (LDL) cholesterol levels should be kept below 100 mg per dL (2.6 mmol per L). Patients with established coronary heart disease whose baseline LDL cholesterol level is 130 mg per dL (3.37 mmol per L) or above should receive a cholesterol-lowering drug. Beta blocker therapy is recommended in patients with a history of myocardial infarction who have no contraindications. Angiotensin-converting enzyme (ACE) inhibitor therapy is recommended in all patients with CAD who also have diabetes or left ventricular systolic dysfunction (LVSD).
Heart Failure. Initial evaluation of patients with heart failure should include the following tests: complete blood cell count, urinalysis, liver function, serum electrolyte (including calcium and magnesium), blood urea nitrogen, serum creatinine, blood glucose, and thyroid-stimulating hormone levels. Serial monitoring of serum electrolytes and renal function also is recommended. A thorough history and physical examination, including assessment of the patient's volume status, is recommended to identify cardiac and non-cardiac disorders that may accelerate the progression of heart failure.
Two-dimensional echocardiography or radionuclide ventriculography should be used to assess left ventricular systolic function, and repeat measurement of ejection fraction is recommended in patients with a change in clinical status or treatment with significant effect on cardiac function.
Patient education and close supervision are recommended to reduce the likelihood of noncompliance and detect changes in body weight or clinical status so that effective treatment can be started. Patients should be encouraged to avoid behaviors that increase the risk of heart failure (e.g., smoking, alcohol, drug use).
Beta blocker and ACE-inhibitor therapy is recommended for patients who have asymptomatic LVSD with recent myocardial infarction or reduced ejection fraction. Beta blockers and ACE inhibitors also are recommended in stable patients with symptomatic LVSD, unless contraindicated. Anticoagulant therapy is recommended in patients with concomitant disease (e.g., paroxysmal or chronic arterial fibrillation, previous thromboembolic event).
Report on Outbreaks of Aseptic Meningitis
Outbreaks of aseptic meningitis associated with echovirus 9 (E9) and echovirus 30 (E30) have been reported in at least seven states this year, according to a report from the Centers for Disease Control and Prevention (CDC). The full report is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5232a1.htm.
During March 2003, several state public health departments noted increased reports of aseptic meningitis, and by early August, seven states (i.e., Arizona, California, Georgia, Idaho, Oregon, South Carolina, Texas) had reported outbreaks associated with E9 or E30. The CDC report summarizes the outbreaks in Arizona, California, Georgia, Idaho, and South Carolina.
In Arizona, 465 cases of aseptic meningitis (rate, 8.6 cases per 100,000 persons) were reported through July 31, compared with 104 cases (1.9 cases per 100,000 persons) reported for the same period in 2002. The highest rate was reported in Maricopa County (12.7, compared with 2.7 during the same period in 2002). As of July 31, the Arizona State Health Laboratory had reported 62 enterovirus isolates, the majority (66 percent) from cerebrospinal fluid (CSF) specimens. E30 accounted for 47 isolates (76 percent) and E9 for one isolate (2 percent).
In California, 1,753 cases of aseptic meningitis (rate, 8.0 cases per 100,000 persons) had been reported through August 5, compared with annual rates of 4.5 to 7.3 from 1999 to 2003. Specimens from 148 patients from 24 counties were submitted for diagnostic testing, and 82 patients (55 percent) had evidence of enterovirus infection by polymerase chain reaction (PCR) testing or culture. E30 was identified from 29 culture-positive cases (85 percent), and E9 was identified from four cases (12 percent).
In Georgia, 320 cases of aseptic meningitis were reported from 50 counties from March 10 to July 23, compared with 227 cases reported statewide during 2002. E9 was isolated from CSF, throat swab, or rectal swab specimens of 24 patients. Enteroviruses were isolated from an additional 24 CSF specimens, and 52 CSF specimens tested positive for enteroviruses by PCR. Patients commonly reported headache, fever, nausea or vomiting, stiff neck, and photophobia.
In Idaho, 38 cases from three adjacent north-central counties were reported from May 21 to July 17, compared with four cases statewide during 2002. Of the 32 patients for whom clinical information was available, 17 (53 percent) were hospitalized with clinical signs and symptoms consistent with aseptic meningitis. E30 was isolated from two of four patients who underwent virologic investigation.
In South Carolina, 82 cases of viral meningitis were identified in Aiken County from April 6 to July 31. The outbreak peaked during May, when 38 cases were reported. E9 was isolated from the CSF of two patients. In June, cases began to appear in multiple counties. By the end of July, 130 cases of aseptic meningitis had been reported. E9 was isolated from 20 specimens (18 CSF and two throat washings); no other enteroviruses were identified. Viral meningitis is not a notifiable disease in South Carolina, so comparative data are not available for previous years.
AHRQ Report on Inhaled Anthrax and Influenza
The Agency for Healthcare Research and Quality (AHRQ) has published a study on key symptoms that may help distinguish inhaled anthrax from influenza and other common respiratory conditions. “Accuracy of Screening for Inhaled Anthrax After a Bioterrorist Attack,” appears in the September 2, 2003, issue of Annals of Internal Medicine, and is available online at http://www.annals.org/cgi/content/full/139/5_Part_1/337.
Results of the study are being used to create the first evidence-based pre-hospital screening protocol designed for response to future anthrax attacks. By helping emergency management and public health authorities rapidly and accurately identify both potential cases and likely noncases, this protocol, once fully tested, can help to preserve scarce hospital capacity while ensuring that patients receive appropriate advanced medical care.
Combining data from the 11 inhaled anthrax cases in the 2001 attacks with historical case reports of 17 additional patients, researchers compared the features of anthrax-related illness with more than 4,000 cases of common viral respiratory tract infections such as influenza. While symptoms such as fever and cough did not reliably discriminate between anthrax and influenza or influenza-like illnesses, others—most notably neurologic problems such as dizziness and confusion, gastrointestinal symptoms such as nausea and vomiting, and shortness of breath—were much more common in patients with inhaled anthrax. Although sore throat and runny nose were present in some cases of anthrax infection, these influenza-like symptoms never occurred without at least one of these other symptoms.
In summary, nonheadache neurologic symptoms, dyspnea, abnormal lung examination, and nausea or vomiting increase the likelihood of anthrax; pleuritic pain, cough, fever, or chills do not change the likelihood appreciably; and headache, sore throat, and rhinorrhea make it less likely. Because this is a rare condition, even among patients with some or all of the high-risk factors, the disease remains an unlikely diagnosis.