Secondary Prevention and Rehabilitation

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1 Secondary Prevention and Rehabilitation Effectiveness of a planned strategy using cardiac rehabilitation nurses for the management of dyslipidemia in patients with coronary artery disease Manohara P. J. Senaratne, FRCPC, FACC, PhD, Jo Griffiths, BScN, Donna Mooney, RCT(A), Leslie Kasza, FRCPC, FACC, Karen MacDonald, RN, and Suzanne Hare, RD Edmonton, Alberta, Canada Background Firm evidence exists for reduction in mortality and morbidity by lipid-lowering therapy in patients with coronary artery disease (CAD), yet a significant proportion remain untreated. This prospective study determined the effectiveness of a planned strategy of management using a cardiac rehabilitation nurse in achieving (1) lower 6-month low-density lipoprotein (LDL) levels and (2) a higher proportion of patients on pharmacologic therapy. Methods A cardiac rehabilitation nurse arranged for the lipid profiles and initiated pharmacologic therapy as soon as possible after the diagnosis of CAD. In phase 1, this planned-strategy intervention group (n = 80) was compared with the usual-care control group (n = 189), where the management was left at the discretion of the attending cardiologist with the assignment to the 2 groups based on the weekly on-call rotations of the attending cardiologists in a nonrandomized manner. In phase 2 of the study all patients (n = 366) were enrolled in the planned strategy of management. Results There were no significant differences in the baseline lipid values between the control and intervention groups. The 6-month cholesterol and LDL values and the percentage of patients on lipid-lowering medications were significantly better in the intervention group (P =.01). In phase 2 the results obtained in the intervention group were duplicated in a much larger group of consecutive patients. The 6-month (millimoles per liter) results in the control, intervention, and phase 2 groups (respectively) were cholesterol 4.92 ± 0.06, 4.60 ± 0.07, 4.30 ± 0.05; low-density lipoprotein 2.91 ± 0.06, 2.68 ± 0.07, 2.4 ± 0.06; high-density lipoprotein 1.18 ± 0.07, 1.12 ± 0.09, 1.10 ± 0.01; triglycerides 1.89 ± 0.12, 1.78 ± 0.09, 1.70 ± 0.05; and on medications 49%, 83%, and 84%. Conclusion A planned strategy of management with use of early pharmacologic therapy with a cardiac rehabilitation nurse assigned to obtain and follow lipid profiles and initiate therapy is more effective in controlling dyslipidemia than leaving the management to the cardiologist. (Am Heart J 2001;142: ) Many clinical trials have demonstrated that pharmacologic therapy of dyslipidemia in patients with coronary artery disease (CAD) results in reduction of mortality and morbidity. 1-4 However, a significant proportion of patients with CAD remain without drug therapy. 5,6 The current study was designed to assess the effectiveness of a planned strategy of management for achieving lower low-density lipoprotein (LDL) levels From the Division of Cardiac Sciences, Grey Nuns Hospital, Edmonton, Alberta, Canada. Submitted October 5, 2000; accepted July 12, Reprint requests: M. P. J. Senaratne, FRCPC, FACC, PhD, Coronary Care Unit, Grey Nuns Hospital, 1100 Youville Dr W, Edmonton, Alberta T6L 5X8, Canada. mano@attglobal.net Copyright 2001 by Mosby, Inc /2001/$ /1/ doi: /mhj and in implementing pharmacologic therapy in a higher proportion of patients with CAD. Methods The planned strategy of management was based on the following: (1) At the time of diagnosis of CAD, a window of opportunity exists to establish an effective treatment plan. (2) Cardiac rehabilitation nurses (CRN) will be required to function as key coordinators to arrange the lipid profiles and pharmacologic therapy. This was felt to be a crucial step in the program because family physicians and specialists left to themselves to initiate lipid-lowering therapy on patients appear to have achieved suboptimal results. 5,6 (3) Each patient will be required to be an active participant. The study was carried out in 2 phases enrolling consecutive patients admitted with CAD to the coronary care unit

2 976 Senaratne et al American Heart Journal December 2001 (CCU) and alive at discharge. All patients were seen by the CRN, which was the usual practice in this hospital. Specifically, the study group was not restricted to patients who enrolled in an outpatient cardiac rehabilitation program who would be expected to have better motivation and thus better compliance. Phase 1 All patients admitted from January to December 1997 were included in phase 1. Patients were admitted under the care of 1 of 3 cardiologists with the CCU functioning as a closed unit. The patients admitted under 1 cardiologist (instrumental in setting the planned strategy of management) constituted the planned strategy group. All other patients served as an observational control group that reflected the existing pattern of practice in this institution. Thus the assignment to the 2 groups was not randomized. It was, however, based on the weekly on-call roster. The planned strategy intervention group. Management was carried out in a prospective manner. In this intervention group, the CRN functioned as the pivotal person who arranged for the laboratory testing and pharmacologic therapy. At the time of admission, family physicians were contacted to determine whether any preceding lipid profiles were available. In the absence of these, a fasting lipid profile was obtained on the day after admission. Even if these values were within the goals recommended, a repeat lipid profile was drawn 6 weeks/3 months after admission to rule out the possibility of a pseudonormalization of lipid levels. After the baseline lipid profile was obtained, a CRN arranged for the appropriate pharmacologic therapy in liaison with the cardiologist. For the patients already on medications at the time of enrollment, the dosage was titrated as necessary. No trial of dietary therapy was given, although all patients were recommended a National Cholesterol Education Program Step II diet modified to achieve a goal of 20% of the caloric intake from fat, together with guidelines to control the total caloric intake to maintain/achieve a body mass index of 20 to 25. Further, all patients (together with their spouses) were encouraged to attend group as well as individual dietary instructional sessions provided by the dietician. The progress of each patient with regard to dietary modification was assessed at these sessions with changes suggested as needed. The patients who attended these additional individual or group sessions were categorized as having intensive dietary counseling. Prescription of the appropriate pharmacologic therapy was based on the following: A statin was chosen if (1) the LDL level was >3.4 mmol/l (>130 mg/dl), irrespective of the triglyceride (TG) level or (2) the LDL level was between 2.6 and 3.4 mmol/l ( mg/dl) with the serum TG level <2.3 mmol (<200 mg/dl) ± a high-density lipoprotein (HDL) level >0.9 mmol/l (>35 mg/dl). A fibrate was chosen if (1) the TG level was elevated to the point where LDL was not calculable; (2) the LDL level was between 2.6 and 3.4 mmol/l with a TG value >2.3 mmol/l ± an HDL level <0.9 mmol/l (However, where only 1 of the 2 [TG or HDL] was abnormal, a statin was chosen as the initial therapy [depending on the relative degree of deviation of the LDL, HDL, and TG levels from the desired goals] with the addition of a fibrate later, if necessary.); or (3) the HDL level was <0.9 mmol/l with the LDL level <2.6 mmol/l and triglyceride levels <2.3 mmol/l. The lipid profile was repeated in 4 weeks with the medications titrated to achieve an LDL level <2.6 mmol/l and a TG level <2.3 mmol/l. Where these goals could not be achieved with a single agent, a combination therapy was used. Each patient was given a booklet providing an explanation of the different fractions in a lipid profile as well as the mortality and morbidity benefits achieved with drug therapy. The desirable goals for LDL and TG were clearly defined. The booklet contained a table to keep a record of the lipid values with the patients instructed to inquire and tabulate results. Thus, by involving the patient actively in his or her care, it was hoped that the adequacy of control would be maintained on a long-term basis. A lipid profile obtained at 6 months was classified as suboptimal whenever the goals for LDL (<2.6 mmol/l) and TG (<2.3 mmol/l) were not met. Reasons for the suboptimal results were evaluated and tabulated. The compliance with the drug therapy was confirmed with the patient with the reasons for discontinuation or nonadherence recorded. Usual care control group. In this control group, the ordering of lipid profiles and subsequent management was left to the cardiologist. However, the education, including dietary counseling, received by the control group was the same as that outlined for the intervention group. The offices of the attending cardiologists as well as those of the family physicians were contacted to obtain results of lipid profiles drawn during a follow-up period of up to 6 months (6 months was chosen because this length of time could be considered adequate to achieve control of the lipid values even after leaving time for a trial of dietary therapy only). The phone calls were made after the 6-month period to ensure that the calls, by themselves, did not initiate ordering of lipid profiles. All patients in the control group were contacted at the end of 6 months to obtain details regarding the usage of medications or the reasons for nonuse. Phase 2 As the effectiveness of the planned strategy of management became apparent during phase 1 of the study, all patients admitted to the CCU under any of the 3 cardiologists (January 1998 to June 1999) were included in the planned strategy of management in phase 2. The patients in this part of the study will be referred to as intervention group 2. Statistical analysis The primary hypothesis was that a planned strategy of management by a CRN would result in better management of the dyslipidemia in patients with CAD. The principal end points selected were the LDL level and the proportion of patients on pharmacologic therapy at the end of 6 months. The LDL level was chosen because the majority of the studies demonstrating mortality and morbidity benefit used the LDL level as the primary criterion for treatment. The proportion of patients on pharmacologic therapy was used as the other principal end point because the use of drug therapy appears to be the most important factor required to favorably modify prognosis. 1,2 The mean ± SEM is given for continuous variables. The cross-tabulations were done on discrete variables with a χ 2 test. Analyses on continuous variables were made with a Student t test.

3 American Heart Journal Volume 142, Number 6 Senaratne et al 977 Figure 1 The percentages of patients on lipid-lowering medications and with optimum lipid profiles (LDL <3.0 mmol/l and TG <2.3 mmol/l) in the 3 groups of patients. UCG, Usual-care group (n = 189); PSG, planned-strategy group (n = 80); PSG-2, planned-strategy group in phase 2 (n = 366). Because there were some baseline differences (although nonsignificant) between control and intervention groups, a multivariate discriminant function analysis was carried out to adjust for these baseline differences. The details of the method have been described previously. 8 In summary, the LDL level at 6 months was recorded as a dichotomous variable with a cutoff value of 3.0 mmol/l (115 mg/dl). An LDL value of 3.0 mmol/l was chosen as an acceptable LDL value when trying to achieve a mean of 2.6 mmol/l (with a value >3.0 mmol/l regarded as suboptimal). The following variables were entered into a stepwise discriminant function analysis program: intervention/control group, sex, baseline weight, baseline LDL, presence or absence of diabetes mellitus, hypertension, family history of early CAD, and history of smoking. Results Phase 1 The clinical characteristics and lipid profile values in the intervention and control groups (n = 80 and n = 189, respectively) at baseline appeared to be similar (Table I, P >.05). The percentage of patients who participated in intensive dietary counseling was not significantly different between the 2 groups. A baseline LDL of >3.0 mmol/l (>115 mg/dl) was seen in 65.5% and 70.7% of the control and intervention groups, respectively (P >.05). The total cholesterol (4.60 ± 0.07 mmol/l) and LDL levels (2.68 ± 0.07 mmol/l) in the intervention group at the end of the 6 months was significantly better than in the control group (total cholesterol 4.92 ± 0.06, LDL 2.91 ± 0.06, P =.04). The proportion of patients on pharmacologic therapy for lipid management was significantly higher in the intervention group (82.5% vs 50.3%, P =.01, Fig- Table I. Clinical and investigational characteristics of the patients in phase 1 (n = 269) Intervention group Control group No. of patients 80 (29.7%) 189 (70.3%) Age (y) 63.5 ± ± 0.9 Weight (kg) Baseline 80.6 ± ± 1.2 At 3 mo 76.1 ± ± 2.1 Sex Male 48 (60.0%) 136 (72.0%) Female 32 (40.0%) 53 (28.0%) Diabetes 19 (23.7%) 30 (15.9%) Hypertension 36 (45.6%) 86 (46.0%) Smoking Baseline Never 33 (41.3%) 63 (33.5%) Current 24 (30.1%) 73 (38.8%) Quit >1 y 23 (28.8%) 52 (27.7%) At 6 mo 9 (11.3%) 27 (14.3%) Family history of CAD 31 (38.8%) 71 (37.6%) On lipid-lowering therapy at time 15 (18.8%) 27 (14.3%) of referral Intensive dietary counseling 48 (60.0%) 118 (62.4%) Lipid profile: baseline (mmol/l) Total cholesterol 5.42 ± ± 0.08 LDL cholesterol 3.43 ± ± 0.07 HDL cholesterol 1.03 ± ± 0.02 Triglycerides 2.17 ± ± 0.11 Lipid profile: 6 mo (mmol/l) Total cholesterol* 4.60 ± ± 0.06 LDL cholesterol* 2.68 ± ± 0.06 HDL cholesterol 1.12 ± ± 0.07 Triglycerides 1.78 ± ± 0.12 Number of patients with the percentage from within that group or mean ± SEM are tabulated. *P <.05.

4 978 Senaratne et al American Heart Journal December 2001 Figure 2 The reasons for nonuse of lipid-lowering medications (MEDS) in the 2 groups of patients. UCG, Usual-care group (n = 94); PSG, planned-strategy group (n = 14). Table II. Clinical and investigational characteristics in the patients enrolled in phase 2 with significant differences between the sexes identified (n = 366) Males Females No. of patients 284 (77.6%) 82 (22.4%) Age (y) 59.7 ± ± 1.1 Weight (kg) Baseline* 85.0 ± ± 1.8 At 6 mo* 83.8 ± ± 1.9 Lipid profile: baseline (mmol/l) Total cholesterol 5.33 ± ± 0.15 LDL cholesterol 3.32 ± ± 0.11 HDL cholesterol* 1.01 ± ± 0.03 Triglycerides 2.29 ± ± 0.25 Lipid profile: 6 mo (mmol/l) Total cholesterol 4.22 ± ± 0.13 LDL cholesterol 2.44 ± ± 0.08 HDL cholesterol* 1.05 ± ± 0.04 Triglycerides 1.74 ± ± 0.11 Diabetes 66 (23.4%) 18 (22.3%) Hypertension 123 (43.3%) 37 (45.7%) Smoking Baseline Never 69 (24.3%) 36 (43.9%) Current 75 (26.4%) 20 (24.4%) Quit >1 y 114 (40.1%) 21 (25.6%) At 6 months 26 (9.2%) 9 (11.0%) Family history of CAD 109 (38.4%) 38 (46.3%) Number of patients with the percentage from within that group or mean ± SEM are tabulated. *P <.01. ure 1). The reasons for not using medications are outlined in Figure 2. In the control group a valid reason for nonuse was not apparent in 41.8% of the patients not on drugs compared with only 14.3% in the intervention group. No follow-up lipid profiles were available in 16.7% and 27.3% of the intervention and control groups, respectively (P =.03). This value dropped to 9.8% in phase 2 with more intensive surveillance as a result of the feedback provided by phase 1. Apart from lack of ordering by the physicians, other reasons for nonavailability of lipid profiles were interim deaths, out-of-country patients, patients refusing medications or follow-up, and patients living on native reserves or in remote communities in the Northwest Territories. The 6-month lipid profiles were categorized as optimal/suboptimal as outlined in the Methods section. The percentages of patients with optimum values in the intervention and control groups were 62.8% and 43.2%, respectively (Figure 1, P =.03). On univariate, as well as multivariate, analysis the variables significantly associated with a 6-month LDL level <3.0 mmol/l were intervention group (P =.001) and participation in intensive dietary counseling (P =.001). The standardized canonic discriminant coefficient for intervention versus control group was and that for intensive dietary counseling was Phase 2 The clinical and investigational characteristics of these patients are outlined in Table II. Of the 366

5 American Heart Journal Volume 142, Number 6 Senaratne et al 979 patients, 309 (84.4%) were on lipid-lowering medications at 6 months with total cholesterol, LDL, HDL, and TG values (millimoles per liter) of 4.27 ± 0.05, 2.39 ± 0.06, 1.11 ± 0.01, and 1.74 ± 0.05, respectively. Of the 57 patients not on medications, 22 patients (38.6%) had lipid values within the desired goals without medications. A further 17 patients (29.8%) had refused to use medications and 5 patients (8.8%) had adverse effects resulting in discontinuation of the medications (the latter group comprised 1.6% of the total number of patients started on medications: 5 of 314 patients). Thus only 13 patients (23.6% of the group not on medications) had a failure of prescription of medications in spite of LDL or TG values that were not within the desired range. These 13 patients constituted 3.6% of the total group of 366 patients. At 3 months, an LDL level of <2.6 mmol/l was achieved in 232 (63.4%) patients (males 62.3%, females 67.1%; P >.05). An LDL level of <3.0 mmol/l was achieved in 318 (86.9%) of the patients. The predominant reasons for suboptimal lipid values were a poor compliance with the diet (as judged by the dietician) in 28 patients (28.6%) and a lack of an adequate magnitude of reduction of the lipid levels by the prescribed drugs in 41 patients (41.8%). A substantial proportion of these latter patients had a mixed dyslipidemia leading to less-than-optimum results achieved with single-drug therapy. Of the 309 patients on pharmacologic therapy, 81.1% were on a statin, and 14.9% were on a fibrate (1 patient = 0.3% on niacin). Only 11 (3.6%) were on combination therapy (statins and fibrates). The extra work involved in the planned strategy of management by the CRN resulted in an increase of a 0.3 full-time equivalent position (ie, 3 half days of work each week for a nurse). The cost for a 0.3 of a position in nursing amounted to an extra cost of Cdn $15, per year (approximately US $10, per year) on the basis of an annual salary of Cdn $52, per year. The 0.3 full-time equivalent position was able to deal with the extra resources needed for approximately 225 patients per year (on the basis of 366 patients enrolled during an 18-month period in phase 2 of the study). There was no additional physician time required for the program. In fact, there appeared to be a reduction in the time involvement by the cardiologists because the CRN dealt with the ordering of the required tests and evaluation of results with implementation of the orders. Discussion A cornerstone of the management of CAD appears to be the control of progression and the induction of stabilization/regression of the atherosclerotic plaques. In the majority of clinical trials, pharmacologic therapy, in addition to a recommended diet, appeared superior to dietary therapy alone in terms of reduction of mortality and morbidity. 1-3,5 In spite of this, a substantial proportion of patients with CAD remains untreated or undertreated. The current study demonstrated that a planned strategy of management using a CRN can achieve better management of the lipid profiles of patients. Discriminant function analysis identified the planned strategy grouping as the most important variable determining a 6-month LDL level <3.0 mmol/l. Intensive dietary counseling was the only other significant predictor, underscoring its continued importance even with concomitant drug therapy. The baseline LDL level, somewhat surprisingly, did not appear to be a significant predictor of a 6-month LDL level <3.0 mmol/l. This finding is likely due to the fact that currently the LDL can generally be reduced to a desired goal with stations in the majority of patients. Literature review Literature review revealed a few studies where a clinical nurse played an active role in dyslipidemia management. 7,9,10 In the study by Becker et al 7 a nurse trained in lipid management was assigned to follow up for a period of two years 30- to 59-year-old siblings of patients with premature CAD. Pharmacologic therapy was initiated after a trial of dietary therapy in those with an LDL level >4.14 mmol/l (160 mg/dl). The nurse care group achieved a significantly higher proportion of patients with an LDL level <3.36 mmol/l, although the magnitude of the reduction in LDL was not statistically significant. This study had the advantage of a randomized design and a longer follow-up. However, it dealt with a much younger and smaller group of patients (mean age approximately 46 years, n = 46). Further, the time commitment from the nurses was more with 3 nurses assigned to the study. A study by DeBusk et al 10 demonstrated the superiority of dyslipidemia management at the end of 1 year after an acute myocardial infarction with a physiciandirected, nurse-managed, home-based care management system. This study had the advantage of a randomized design and a slightly longer (1 year) period of follow-up compared with the current study. However, only patients <70 years old were recruited, with only 65% of the patients included in the study. In the current study, the results are reported for all patients admitted with CAD. It can only be speculated about the reason(s) for the suboptimal results in the management of dyslipidemia when the process is left in the hands of the cardiologists: (1) lack of action/desire on the part of physicians and patients with regard to preventive therapy as opposed to symptomatic therapy, (2) the lack of adequate physician remuneration for repeat patient visits, which are a prerequisite for evaluation of results, prescription, and titration of medications, (3) recommen-

6 980 Senaratne et al American Heart Journal December 2001 dations by cardiologists (without direct action) to the family physician with lack of follow-up action by the latter, and (4) a trial of therapy with diet alone undertaken with subsequent loss to follow-up of patients who often fail to return as the symptoms that initially brought them to the physicians are under control. To improve current practice, the following suggestions (as used in the intervention group) could be considered: (1) Physicians should avoid a trial of only dietary therapy because pharmacologic therapy has been shown to be superior in many clinical trials, where the extent of dietary counseling offered would be expected to be superior to that available in usual clinical practice. In addition, a study by Hunninghake et al 11 demonstrated that the magnitude of the reduction of LDL achieved by the National Cholesterol Education Program Step II diet was minimal (5%) compared with that achieved by a similar diet and lovastatin (32%). (2) The physician (family physician/internist/ cardiologist) who makes the initial diagnosis of CAD should accept the responsibility for initiation of pharmacologic therapy. In short, prescription of lipid-lowering agents should be concomitant with prescription of nitroglycerin. (3) Treatment should commence with an appropriate dose of the selected medication (on the basis of the magnitude of reduction of LDL required to achieve a level <2.6 mmol/l) rather than at the lowest dose. This would minimize the number of visits required to reach the goals, improving efficiency. Current study: Summary and implications In the intervention group, a CRN was used to circumvent the problems associated with management by the physician alone. However, the other factors as mentioned in the previous paragraph also contributed to the improved control of the dyslipidemia. For this strategy to be used in a widespread manner, use of a nurse would be the most practical solution. In the hospital setting, CRNs can be used for the purpose, although an additional cost would be involved. Nevertheless, given the significant reductions in the incidences of death, myocardial infarctions, strokes, and hospitalization resulting from lipid-lowering therapy, it is anticipated that the benefits accrued would justify the cost. In an outpatient setting as well, nurses are often available in many group practices and thus can be easily trained to follow a similar strategy of management. In solo practices where a nurse might not be available, an option that can be considered is the use of a CRN from a hospital to visit the practices on a periodic basis to manage such a program. Financial support for such an outreach program may be pursued from the pharmaceutical industry. Thus the planned strategy could potentially be adapted in the primary care setting. A cooperative approach of this nature could provide potential benefit for patients (improved long-term morbidity and mortality) and physicians (better practice management as per guidelines) while achieving the necessary return for the pharmaceutical industry as well. In phase 2, the practical feasibility of the planned strategy of management was demonstrated prospectively in a larger group of patients. Only 18.5% of patients were not on lipid-lowering therapy at the end of 3 months. Within the latter group, 43.2% of the patients had lipids within the desired goals, providing a valid reason for lack of prescription of medications. Nevertheless, 8 patients constituting 21.6% of this group (2.8% of the total group) were not prescribed medications, demonstrating that some patients remained untreated even in a carefully monitored setting. Most of these patients had marginally abnormal LDL and TG values with a trial of dietary therapy chosen in spite of the initial desire to avoid dietary management only. The current study suggests that such a desire should be resisted because the ultimate outcome often is suboptimal lipid values at 6 months. Further, the Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) trial demonstrating that early (within hours of admission with unstable angina/non-q-wave acute myocardial infarction) treatment with atorvastatin was associated with a significant reduction in coronary events underscores the importance of early pharmacologic therapy. 12 The final group that needs to be looked at is the patients who refused medications, constituting 35.1% of the patients not on medications. This group often consists of patients who are well educated and well acquainted with their disease and the therapies available. They often appear to have a concern regarding the liver and muscle toxicity and other potential adverse effects related to long-term use of medications. Thorough explanation of the results of clinical trials demonstrating benefits of medications may help to alleviate these concerns. The final choice of treatment, however, will remain with the patient. Limitations The current study is limited by the fact that the control and intervention groups were not randomized groups but rather a comparison between the practice patterns that existed versus a planned modification of the program to achieve better results. However, the goal in the study was to demonstrate that a program using a CRN as a pivotal part would be superior to the current pattern of practice, leaving the responsibility to cardiologists. Further, a randomized trial could have artificially improved the results in the control group arm because the greater scrutiny brought on by the trial could have led to better management by the cardiologists, which may not necessarily be replicated in clini-

7 American Heart Journal Volume 142, Number 6 Senaratne et al 981 cal practice. In the current study, phase 2 was specifically done to confirm that the results obtained in the intervention group in phase 1 could be replicated in a larger group of patients. The follow-up lipid values in the control group were not available in approximately 27.3% of the patients. Although no lipid profiles that were done were missed, it is possible that the patients who were followed up had worse lipid values, biasing the final results. Nevertheless, given the current belief that almost all patients with CAD should receive pharmacologic therapy, the absence of follow-up lipid profiles in 27.3% of the patients would be considered suboptimal. The current study was also limited by the relatively short period of follow-up. Whether the results obtained with the planned strategy of management would be maintained in the long term is unclear. The family physicians were instructed to maintain life-long lipidlowering therapy, with the patients also advised regarding the same. It is hoped that the booklets given to patients with instructions to tabulate their lipid profiles (with LDL and TG goals identified) may also help in maintaining therapy. Currently, plans are underway to contact all patients at the end of 1 year. In summary, the current study demonstrates that a planned strategy of management of dyslipidemia by a CRN (in liaison with the attending cardiologist) as an essential component of the program is superior to the usual practice of leaving the responsibility to cardiologists alone. Such a strategy can be adapted wherever a trained nurse is available to follow an algorithm of management. References 1.Scandinavian Simvastatin Survival Study Group.Randomized trial of cholesterol lowering in 4444 patients with coronary heart disease: Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344: Sacks FM, Pfeffer MA, Moye LA, et al.the effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels. N Engl J Med 1996;335: LIPID Study Group.Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998;339: Summary of the second report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel II). JAMA 1993;269: Waters D.Cholesterol lowering: should it continue to be the last thing we do? Circulation 1999;99: Brown AS, Bakker-Arkema RG, Yellen L, et al.treating patients with documented atherosclerosis to National Cholesterol Education Program recommended low-density-lipoprotein cholesterol goals with atorvastatin, fluvastatin, lovastatin and simvastatin. J Am Coll Cardiol 1998;32: Becker DM, Raqueno JV, Yook RM, et al.nurse-mediated cholesterol management compared with enhanced primary care in siblings of individuals with premature coronary artery disease. Arch Intern Med 1998;158: Hsu L, Senaratne MPJ, De-Silva S, et al.prediction of coronary events following myocardial infarction using a discriminant function analysis. J Chronic Dis 1986;39: Blair TP, Bryant FJ, Bocuzzi S.Treatment of hypercholesterolemia by a clinical nurse using a stepped-care protocol in a nonvolunteer population. Arch Intern Med 1988;148: DeBusk RF, Miller NH, Superko R, et al.a case-management system for coronary risk factor modification after acute myocardial infarction. Ann Intern Med 1994;120: Hunninghake DB, Stein EA, Dujovne CA, et al.the efficacy of intensive dietary therapy alone or combined with lovastatin in outpatients with hypercholesterolemia. N Engl J Med 1993;328: Schwartz GG, Olsson AG, Ezekowitz MD, et al.effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes. JAMA 2001;285: