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Statins in the Medical Management of Postoperative Coronary Artery Bypass FREE TO VIEW

John C. Alexander, Jr, MD
Author and Funding Information

Affiliations: Hackensack, NJ
 ,  Dr. Alexander is Professor of Surgery, University of Medicine and Dentistry of New Jersey (UMDNJ) at Newark and Chief of Cardiac Surgery at Hackensack University Medical Center.

Correspondence to: John C. Alexander, Jr, MD, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601; e-mail: jalexander@humed.com

Chest. 2005;127(2):423-424. doi:10.1378/chest.127.2.423
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This issue of CHEST (see page 455) contains an article by Khanderia et al that describes an experience at the University of Michigan concerning the incorporation of statins in the medical management of postoperative coronary artery bypass patients. The authors do an excellent job of describing the basic science that supports the incorporation of statins into the postoperative medical regimen of patients who have undergone coronary bypass grafting. There appears to be little doubt that statins are associated with improved outcomes in these patients. The evidence appears to be undeniable that statins should be a part of every postoperative coronary bypass patient’s regimen unless there is some genuine reason for exclusion such as hepatic toxicity.

The authors describe an effort that they made to integrate this paradigm shift into their hospital. They undertook an educational program that was targeted at the surgeons who were the final decision makers. Their educational efforts are commendable; however, they fell short of the optimal target in terms of the percentage of patients receiving statins either in the short or long term. The authors did point out that protocol patients were more likely to receive statins than the retrospective controls subjects. Statins were initiated in only 75% of those patients believed by the authors to be eligible. The authors monitored liver function study results and cholesterol target levels in approximately half of their patients. There were no cases of rhabdomyolysis or significant elevation of liver functions studies in the authors’ study group. The statin treatment rates dropped to 67% of eligible patients still receiving statins at 6 months following discharge.

The authors quite rightly point out that their protocol was “passive.” The incorporation of statins into the postoperative management of patients depended upon an educational effort to be followed by a change in practice patterns, which in retrospect did not achieve compliance at the level the authors had hoped.

The surgeons involved in this group of patients had concerns about statin therapy, in that they believed that hepatic dysfunction following surgery was relatively common, and they did not want to compound that with the addition of statins. The authors’ study documented that liver function study results did not significantly deteriorate in patients placed on statins, which is likely reasonable evidence that the concerns about initiating statin therapy are probably overly cautious.

The net benefit accrued to patients by putting them on statins probably outweighs to a significant degree the potential for complications associated with statins. The authors mention in their article that they are making efforts to overcome the resistance to the incorporation of statins into their postoperative management. It will be interesting to follow their efforts.

We have taken another approach to this problem. We have made initiations of statins “semiautomatic” following coronary artery bypass surgery. This approach has necessitated that the caregivers do something “active” in order to discontinue statins. This approach has resulted in >90% compliance with the recommendations that patients be receiving a statin drug at the time of discharge. We do not have data to document what percentage of our patients are receiving statins at 6 months. It may be improper to conclude that our approach to the management of these patients while in the hospital results in better long-term compliance. It does suggest, however, that a more active approach to the initiation of statins is more productive in getting patients discharged receiving this important medicine.

This article points out a very interesting problem in the delivery of medical care in general. Guidelines have been put together for almost every illness and medical condition imaginable, and they contain the very best evidence available about the management of patients with the various problems that they target.

Achieving compliance with guidelines has presented an extremely challenging problem in a general sense. The authors’ article demonstrates the difficulty of using the “education” approach to achieving compliance with consensus guidelines. As we all struggle with this particular issue, I am convinced that a more active approach to the incorporation of consensus guidelines is the best way to achieve greater levels of compliance. Information technology can be used as a prompting mechanism so that once a diagnosis is established it would require an active intervention on the part of the caregiver in order to prevent “the right thing” from being done. This approach to medicine raises the specter of “cookbook” approaches, “Big Brother,” and the loss of doctor/patient interaction. All of these issues are legitimate and of concern; however, it will become progressively more important for us as a profession to face and solve this issue. In an age of consumerism, our customers deserve our very best. It’s clear that at times we miss that mark. This article is documentation of that fact. A conscientious group of physicians in an excellent institution did this work and wrote the article. The health-care providers involved in the care of these patients clearly have the very best interests of their patients in mind; however, when we look at the results of their attempt to include statins in the postoperative management of cardiac surgery patients, a fairly straightforward clinical recommendation, we and they are disappointed at the level of compliance. Another approach is needed.




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